My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
ARCHIVED REPORTS XR0000618
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
C
>
CENTER
>
121
>
3500 - Local Oversight Program
>
PR0544166
>
ARCHIVED REPORTS XR0000618
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
2/22/2019 5:33:43 PM
Creation date
2/22/2019 1:55:27 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
ARCHIVED REPORTS
FileName_PostFix
XR0000618
RECORD_ID
PR0544166
PE
3528
FACILITY_ID
FA0005252
FACILITY_NAME
GREYHOUND LINES INC
STREET_NUMBER
121
Direction
S
STREET_NAME
CENTER
STREET_TYPE
ST
City
STOCKTON
Zip
95202
APN
13730011
CURRENT_STATUS
02
SITE_LOCATION
121 S CENTER ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
WNg
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
148
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
1 >I <br /> F t <br /> t F <br /> ACCIDENT REPORT FORM <br /> (Continued) <br /> _13. How did the e accident occur?_ <br /> µ (Dekmoe fully the"events wretch resulted in the <br /> injury or occupational illness. Tell what happened'andihow. Name objects and <br /> substances involved. Give`�detatls'ot all factors which"led ItIo'accident. Use separate <br /> sheet"for additionai space.) <br /> 14 Tome of accident: <br /> 15. ES WITNESS` <br /> TO ACCIDENT , (Name)'- (Affiliation) (Phone No. <br /> (Name)p,, ' (Affiliation) (Phone No.) <br /> (Name)` ` t , (Affiliation) (Phone No.) <br /> ti <br /> OCCUPATIONAL INJURY OR OCCUPATIONAL ILLNESS <br /> 16 Describe the u ajury'or illness m detail and{indicia ',the part of the bodv <br /> affected. -� - <br /> Y*Y <br /> + At <br /> 17: Name ,,the object or substance which directly, injured the emplovee. (For <br /> `exampie, object whtcli 'struck employee; the vapor or poison inhaled or <br /> swallowed; the chemncal_or radiation which irritated the skin; or in cases of <br /> strains, hernias, etc., the`object the employee was lifting, pulling, etc. <br /> i <br /> 18. Date of injury or initial diagnosis of occupational illness <br /> (Date) <br /> 19. Did the'accudent result in employee fatality? (Yes or No) <br /> to q=La i/000s r <br />
The URL can be used to link to this page
Your browser does not support the video tag.