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ELSE TYPE ALL INFORMATION.IF POS State of California MAIL ORIGINAL DIi E&LY TO: MAIL 2 COPIES TO: Dept. Of Industrial Relations Gatea McDonaid OSHA Case . EMPLOYER'S REPORT Div. of Labor Statistics 1330 Broaaway. Suite 1630 or File-No. OF OCCUPATIONAL P.O. Box 603 Oakiana. CA 94512 San Francisco, CA 94101 x151832.0301 INJURY OR ILLNESS :LLL X EUTEI, XE rYPE"ITER ALIGNMENT GUIDE - .^ICA X X X ELITE.X X X ilifornia law requires an emoioyer to repaint within five days every industrial injury or occupationat disease which:ta►Results In lost time oeyond the day of injury. to)requires medical treatment other Man first aid. PLEASE NOTE• In addition, it death results or it the intury o• ttlness: fa) Requrres Inoattem hosdttaturation of xe than 24 hours for ether than medical observation: or (b) results in toss at any member of the body:-or (c) produces anv serious degree. of permanent Aigurement,then the nearest district office at the California Division of Occucationat Safety and Health also must be notrhed immediately by taisonone or taiewaph; . Is nouticatipn is not required.howsvar.d the injury or death results from an accident on a public street or highway. 1,RRM NAPE OWENS-BROCKWAY GLASS CONTAINERS I&POLICY NUMBER KEArs00NOT USE ttflt>: 2.MARJW ADDRESS 04WMW gm Seem.CJtr.DPr t;�6WIM• P.O. Box 30 206.PMIDttE Ni1MBER Tracy, Ca 95378-0030 209) 836-8200 t;Wttto 7 LOCATION-IF DIFF"ENr FROM MA^ADDRESS';%ripper Ana aftm.Cih.ZIPI 14700 W. Schulte Road Tracy, Ca 95376 7A.LOCATION CODE O022 u.NATURE OF BUSINESS eq..OWN"ouvp,aii Wn0N=W W=W,rwsr.0".weOtMNdlalar Manufacturers of Glass Containers S•STATE UNEMPLOYMENT INSURANCE ACCT.NO. 342-6747-6 ae.TYPS!OF EMPLOYER; PRNATESTATE' CITY COUNTY OtS OTNq GOVERNMENT—SPECIFY' ilmDko rlRY. X 8.EMPLOYEE-HAVE n 7.DATE OF BIRTH IMM-006tH OCCUPATION . z tit- ��r-z�� ;�.%l /�/��-G• I !.NOME ADDRESS INIarlAar Alq&IgA1.tarry.DPI �' c 806.PHONE Nt MBER W i+.SM Mae F�ryla.. 10.O=UPATION(flpr.pa IllM.not•D�[+Aa Aannnr r'ernA a r+lrrrY! It.SOCIAL SECURITY NUMBER 12.DEPARTMENT 1��EGUTAKY EMPLOM AAW- . M HOURS USUALLY WORKED:HOURS PER DAY 118,DAYS PER WEEK 17x.TOTAL WEEKLY HOURS TZL7/2'v�OA'a.ov t >F lepttR! 5 aaAar w.r.wAOAA AAAVrrrdy 8 40 14 GAOSa WAGESrSALARY- PIM. HOUR PAY WEEKTWO WEEKS MONTH OTHER--SPECIFY , X DAV8"M Vff=x 7.WHERE DID ACCIDENT OA EXPOSURE OCC.tFi7'fkUner Anti SWOK Clry) t 906.COUMY - - -- tS&CIN EMPLOYER'S PREMIS£S7 14700 W. Schulte Rd. , Tracy Ca San Joaquin YES X .,O *TmyHOURS 6 wHAY WAS EMPEOYEE DOING WHEN R&JUREOT m4em as 6000".IaArWi r 10018;AOnr011Aln'0r m,urw W=wee wrrq.l < 771 7 YYElKL17 WAGE t 7 NOW O+O THE A= ENr OR"PpSUgE OGCIJR7 TPNar MONWAa Ap1y hM AYMnA cur r+wrrw n m,w s ApIAIA�ApwrAt arsarw•rAA.nr napPwra 11/ra nvnr A rta00errra: . P=O SAA TOME A= nom.! - COMM N�l>r!E OF 1tL1URY 16-Oa1ECT CR SUBSTANCE THAT DIRECTLY I LAMED EMPLOYEE*. GOAl1Aer cut fflumm"1bR.n Comm of 1111,11m.ar aWq M y 9" Me mAef m*mm"*-■Ouch�or wmn Aftm ft r.we"ow or Dot"n�pY1~-0r swAlWrraC. ar -";c +10 wp+ro.r� PAW Ole amy t` 19A.DESCRIBE TME iraA1RY DR ttl,NES!a.g•oa.X"M•a cw&777-- aw 1sA •P. 19L PART OF eOOY AFFr-CTPD A. pApc on.1rhr:'rgnr M.Re. .. .��.v. 01 9 SOINIC['. . 20.NAME AMD AbDRESS OF PHYMCIAN {Nexntwr aha SeaA1:Cay.Zin 445 W. Eaton Ave Tracy, Ca 95376 ACCMVerTyn 21 IF NTALIZEMJILApe AND ADDRESS OF HOSPITAL lNuwAm And s"w.GtV.ZIPI 17.DATE OF INJURY ORESa DIA. emomme 10tr0 At IrAAt arrA tuY . .urA•D4YY1 �-TIME OF DAY A.p1. p.m, 2tdA7Y o0rn aRAr arA.i}lrri/7 Aa4- ++At.Du.rn NO YES—aAM Lau Waked:' u.HAS EMPLOYEE RETURNED TOwoRltt {Mm-myVt 24 Dip EMPLOYEE DIE? IMIN006YY1 OUT WrCR NO.gill off Nix Yen.Attie fvuwo*'L-' NO - YES—Dog.W D.anc COpfJ3 MwAd p PYPA p tn,rnl _ iW 006 Pott Coyle i IPlant Nurse ea2o lf1EY,51