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• r APR 29 194 OB:41 r.c <br /> Near MBS <br /> 1 , Etnp1eaye�e � �lirior Injury <br /> No Injury f ) <br /> `Cust<omc�r �( Prop. Damage ( 1 <br /> Food 4 Tess <br /> L STORE iNC1DEN7 REPORT <br /> I St&e Name: b Address <br /> i. PreparedbY: . �riate, j9 Store Phoneg <br /> S. Date Reported Claim# <br /> a AM, <br /> . Dateofinoidar t � t9 c .Tirt G.�. �•M.QSun.0Mon.Cl Tues-'wed.ClThur.OFri.CIS&t. <br /> Exact Location:— Fia&ae JKMeat 0 Ueli Cl Frozen 90airy 0 Groc. aisle# <br /> k9e specific: 0 Bakery 0 Liquor 0 Checkout stand# Gl Frant an <br /> (check arse) Near what shelf item (name product)? i C r C4 dw - — - <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> } <br /> o. Tel: No, ("forme)�, } lei_ No.(work)( ) <br /> Emplay"s InVol retl: <br /> Name: �n n C. r�t[. —_ _ Address N t. ►r _ - - t <br /> 2. Tet;(home)T5PI <br /> 3. Chian-up 0 Help customer 0 Taking photos C3 Obtaining information 0 Qrher <br />