|
EASE TYPE AUL LHF0FIMATiON.IF pOSSI" ...
<br /> State of California MAIL 6RIGINAL DI'R—O TLY TO: MAIL 2 COPIES TO:
<br /> EMPLOYER'S REPORT Div.
<br /> Of Industrial Relations Gates McDonald. OSHA Casa.
<br /> Div. of tabor Statistics 1330 Broadway. Suite 1630 or File Na
<br /> OF OCCUPATIONALP.O. Box 609 Oakland. CA 94612
<br /> San Francisco, CA 94101 4151832-0301
<br /> INJURY OR ILLNESS
<br /> DICTA l X A ELITEI'< X X ryPEWRITER ALIGNMENT GUIDESCA
<br /> LUXy y writ .S X X• y y
<br /> /1 X X
<br /> elifomla law requires an err,ployer to room win ft five days even,Industrial iniury or occupational disease which,(a)Results in lost time beyond the day of iniury,
<br /> Ib)requires meatal treatment other than first aid. PLEASE NOTE: In addition. It death results or If the iniury o, Illness:la) Requires inDatterrt fictionalization of
<br /> ire than 24 hours for other than medical observation: or (b) results in loss of any member of the body:-or (c) produces anv serious degme of parmanem
<br /> afigurement.then the nearest district offios of the California QiVislOn at Occupational Safety and Health also must be notified immediately Dy twetxtone or ie"Waph:
<br /> its notification is not required,hOweve►:tf the iniury or death'results from an aCadern on a public street or highway.
<br /> t.FIRM NAA*
<br /> OWENS-BROCKWAY GLASS CONTAINERS ,A.POUCYNUMBER PULM&DONOT
<br /> 2.MAILING ADORE$ti (NLMMW OW pe Cin,.IIP) CCLU M
<br /> P-0- Box 30 u PHONE NUAI9ER
<br /> Tracy, Ca 95378-0030 209) 836-8200 CAaaNO..
<br /> T LOCATION.IF DIPMEW FROM MAR AOOREaa I oneii,00 S"W.Co.MM 3A,LOCATION CODE
<br /> 14700 W. Schulte Road Tracy, Ca 95376 0022
<br /> 4A-NATURE OF BUSINESS a. ., Ow1�IStMt'
<br /> 9 Pa,nwq Ealyacar.-olelaa9laPte,ywrrup, .ale. S.SPATE UNEMIKOYMENT INSURANCE ACCT.No.
<br /> Manufacturers Of Glass Containers 342-6747-6
<br /> As TYPE OF EMPLOYER: PRIVATE' STAT! CITY COUNTY DISTRILTT ~
<br /> X OTHER GOVERNMENT--sPEGF1r IIrD11iTRY
<br /> e EMPLOYEE NAME
<br /> v' 7.DATE OF BIRTH IMM-00-M
<br /> Z64Z OCOWATTON
<br /> a.NOME ADDRESS iNUnlaW wo syaw.Carr,am � /� 7 B&PHONE NUMBER
<br /> 0.SEY: ,Allii FTny,a 10.Ot.CUPA tpagllgr pI m,a•not NPse,AI 40-m T r MO 01 -
<br /> NAY/ 11.SOCIAL SECURITY NUMBER '
<br /> 12.DEPARTMENT IN WHICH REGULARLY EMPLOYED S "- f�;7D_S AM,
<br /> S / 12A.OATfEQyFF�N/IRS IMI44X).1/Yj
<br /> 13.HOURS USUALLY WORKEO:HOURS PER oAY - 13A.DAYS PER WEEK 130.TOTAL WEEKLY HOURS Ix^iMA�r wndaau�r 41 your b
<br /> G O -V:S
<br /> p � PNIUII lrrrw wwrw w�w7'rar ox HOURS
<br /> 4Q
<br /> I� (IRO0.4 wAOES/SAI.ARY� PER'. HOUR DAY WEEP( ri10 WEEKS MONTH OTHER—WECIFY -..
<br /> $ X oars FOI wilt
<br /> 7.WHERE pip ACCIDENT OR EXPOSURE OCCLW iM a e,see Sam.C,lY1 „A,COUNTY 178.ON EMPLOYER'S PREMISES?
<br /> 14700 W. Schulte. Rd. , Tracy Ca San Joaquin.TP�W.....a uurq.r YES- Q X wt> IaY.NouRs
<br /> 6 WHAT WAS EMPLOYEE DOINO WHEN IIrn.IRED'T rpmeew a SPOON&RMPI 40U.0""r or wweriel y,a - .
<br /> ..
<br /> MEMY WAG&
<br /> r 7 HOW pro 7HE ACCIpEHT OR EXPOStrRE DS.CURT IP4�rorreNlla aM,Y I,la*Varna elw rwem"M w wY or eamee mlr amager.TON whf iIaIPlnTrs hew a nappnra,I.
<br /> wfal Wr Froa/aY MMT&M nae�gwY.l -
<br /> COUNTY.
<br /> MATURE dF OLAAIY
<br /> re-ORIECT OR StI&WANCE TWAT DIRECTLY rNJURW EMPLOYEE a.g.. the warr,na
<br /> Mw,as am wr!�1;r caneA is mum wo we"nP w Is".PW",AIC✓ An1p1pf�++.Au S AyA'r or Wh'M wrucrt nxn-trw IN a TWooml Iw+we or 3W4""W Diff -
<br /> _ t c -rte PART OF aODY
<br /> t9A.DESCRIBE THE*WAY OR RLNESS a.q.,011.wrtR Nobs,em rprl. Y
<br /> fila.FART OF BOGY AFFECTE!?e.g..Dalt MR w+Nf.nght VM.wC.
<br /> M NAME AND ADDRESS OF PHYSCUM (Numm,W4 gym.CAV,Zip, .
<br /> 445 W. Eaton Ave Tracy, Ca 95376 ACCO MTTrre
<br /> 21 IF HOSPrrALIZEM NAME AND ADDRESS OF PNTAL INumbera w Wow.a 21P,
<br /> M.DATE OF INJURY 6R L~ �y-{�/L/.? (/�G%!� �-G��� ��•�,-6 `;.
<br /> .ur11,14304Y) , � 2S.TIME of DAV a.T. 24}iW Mnworw Ie..r I�.r a+.A„I ory•s waI alr�r 1Iw+nMn ~�- :.
<br /> YES—OYa INTI Wer,o�
<br /> 23.HAS EMPLOYEE RETURNED7VVOR" (M1AaGYY) 26.OtOMAPIL
<br /> Die? tMM-0DYY) E]RtENTOF
<br /> No.Still all WON !�el.tlab rw,a...... • /�
<br /> YES-0m of Dedw-
<br /> copaQ�=: .
<br /> aa,p a fIYOa ar erTTl _. -
<br /> ff0• Da1r
<br /> Pett Coyle Plant iVursp
<br /> '-
<br /> t42P PlE+r.3,
<br />
|