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'ASE TYPE ALL INFORMATION.IF POSSOLE <br /> State of Callfamia MAIL ORIGINAL 6flA&LY TO- MAIL 2 COPIES TO: <br /> EMPLOYER'S REPORT Dept. Of Industrial Relations Gates McDonald OSHA Gas&., T <br /> Div. of Labor Statistics 1330 t3roadway. Suite 1630 or File No. <br /> OF OCCUPATIONAL San <br /> Box 603 Oakland. CA 44612 <br /> $art Francisco, CA 94101 4151832-0301 T <br /> INJURY OR ILLNESS <br /> .x 22 ELITEt1l 9 + rYPE"ITER ALIGNMENT GUIDE <br /> 'ICA XXX ELITE= <br /> liloni'a law renulres an emctayer to report within five days every industrial inlury or occupational disease which:(a)Results in lost Ome Devon' the day of iniury, <br /> 110) requires maotcal treatment other Iliad tlrst aid. PLEASE NOTE: In addition. If Death resuns or It the iniury a, illness:iai Wedulres inoauem hdspnalt2atlon of <br /> ,re trian 24 hours for other than medical observation: Or (b) results in loss of any member of the botlr.-or lc} produces anv serious oegrs* at oermanent <br /> llqurement.then the nearest district Ottiee at me California Division of Occupaeonai Safety and Fteaith also must be notified Immediately by teleohpne or.tetewson. <br /> s notdleation Is not required,however,-d the mlury or death results from an accident on a public street or highway. <br /> I FIRM NAME <br /> OWENS-BROCKWAY GLASS CONTAINERS I&POUCY NUMBER <br /> PLEAT[OO rear. <br /> U="a . <br /> t.MA41N0 ADCRJ= INInlsar Ma MW Cllr.an COLUMN <br /> P.O. Box 30 Tracy, Ca 95378-0030 x209)Nu836-8200 CAM*0... <br /> 3 LOCATION.IF DIFFERENT FROM MAL AODRESa 0&jWftW ria anaar.QZIP} 'W LOCATION CODE' <br /> 14700 W. Schulte Road. Tracy, Ca 95376 0022 <br /> LA NATURE OF BUSINESS cq,,psalanq cotmaom,wlaraareOwr�reP <br /> atanar,aawrwla.nepl,�, NT S.STATE UNEMPLOYMEINSURANCE ACCT.Nd. <br /> Manufacturers of Glass Containers 342-6747-6 <br /> AS.TYPE OF EMPLOYER; - <br /> OOL <br /> PRIIVME" STATE C" COUNTY DISTRICT OTHER GOVERNMENT—SPECWY INDUSTRY' <br /> X <br /> R EMPLOYEE NAME 7_DATE OF BIRTH IMM-00.YY1 <br /> OCCUPATION <br /> 6 IIOarE ADORE <br /> 59 INunlar-ane 61fe1F Cp1t, aA.PHONE NUM6EgA <br /> � � <br /> w.OCCUPATION maCq/u&RD mM,no"0C*G sarnv r trm al lnmvi I1.SOCIAL SECURITY HUMBER <br /> Q.DEPARTMENT WHICH REGULARLY E 1 <br /> �j <br /> 12A.DATE OF HIRE(MFDO" <br /> 13.FgtlRSUSUALLT WORfKED�D!HOURS <br /> PER DAY 13A.DAYS PER WEE)( 131L TOTAL WEEKLY HOURS I r'I aq m0e« o D"T IIIW� <br /> 8- <br /> 5 40 POW*Woo rratlw aaaretlae l <br /> to GROSS WAGESISAUIRY' BER HOUR DAY wM TWO WEEKS 1.10NTN OTHER—SPECIFY <br /> X ""PER wEE1C <br /> ' X <br /> S.WHERE 1010 ACCIDENT OR EXPOSURE OCCUR?ftntaa►rq Straw.Cd,, ISA.COUNTY 151L ON EMPLOYER'S PREMISES? • <br /> 14700 W. Schulte Rd. , Tracy Ca San Joaquin YES X D wttaa.YHOURS <br /> 5 WHAT WAS EMPLOYEE DOING WHEN al1IJiIEDt as■oaso:eaa,IMyv,Otla:, Tarry tM <br /> WERKI.T WAGE <br /> 7 NOW 010 THE'ACCiOENT OR EXPOSURE O=M? eaaallee hMIY IM ovemm-air eawraaa w"w'w 0mlorwnn a.....-faH�w hpPnre ane Pew a naaorre. <br /> Fyay w aaea/M arlaw a neeeaara.l <br /> COUN" <br /> l <br /> NAZts�OP IrLtURY <br /> a OBJECT OR SUSSrANCE THAT DIRECTLY INJURED-EMPLOYE£a.q.. Ina rnat:rAm anmlee dem r <br /> gwlae.a wnw r tltupe Irrn�Ina.aper or Doom Innraa.« awaaeres, e+e <br /> .Ylaaaeal air Irr uo Ira snrl:w cooed a tltrarr. M w M ".put".NG a <br /> PAIR OF BODY, <br /> 9A pESCperIVEETTHE INJURY OR RLliEA_S e$.cis,1�M��J*Wtu w Skin nem.Or- Ida.PART OF BODY AFFECTED'a.q..dace.tae runt:nqm en,wa - <br /> Z_ <br /> _c. SCISICE' <br /> 0-NAME AD ADDRM OF PHWJIOGN rieualpr dna jsww.Gey.ZIPi <br /> 445 W. Eaton Ave Tracy, Ca 95376 ACCUMMTY" <br /> I IF HOSRTAL=NAME AND AOORM aF HOSPITAL {Numiew ane Stray:Gly.nPl -. <br /> 2-DATEMMSOP Y" ILLESS <br /> OR N 27.TIME OF DAYAmdna eay'a <br /> M.Old nnPleyM teM�al laaal fta A.Qa. <br /> . p.m. were Mir ilia rrnwyJ <br /> NO YES-.ONO LaY wa.MW <br /> s.HAS EMPLOYEE R£n1RNEO To wORKT (M 4 1C." ZL DID EMPLOYEE DIET (MM-DO-YY) Unwi TOF <br /> eLlIURV <br /> NO.pill Oft rlOrk Yes.date raturroa­ NO - vE3—Doli er Munn <br /> we a PTFa w Itrra1- - <br /> +de nolo. <br /> Patt Coyle ant N <br /> X=IREv.51 <br />