ARCHIVED REPORTS_DRYWELL CLOSURE AND INVESTIGATION

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ATTACHMENT B ACCIDENT REPORT FORM This form is required by Public Law 91-596 and must be Case of File No. kept in the establishments for 5 years. Failure to maintain can result in the issuance of citations and assessment of penalties. Location of Office: 1. Name 1 2. Mail address (No. and street, city or town, State, and zip code) 3. Location if different from mail address Inured or III Employee 4. Name (First, middle, and last) Social Securi No. 5. Home address No. and street, ci or town State and zi code Female ❑ 6. Age 7. Sex Check one Male ❑ 8. Occupation (Enter regular job title, not the specific activity he was performing at time of injury.) 9. Department (Enter name of department of division in which the injured person is regularly employed, even though he may have been temporarily working in anothe department at the time of injury) The Accident or Ex osure to Occu ational Illness If accident or exposure occurred on employer's premises, give address of plant or establishment in which it occurred. Do not indicate department or division within the plant or establishment. If accident occurred outside employer's premises at an identifiable address, give that address. If it occurred on a public highway or at any other place which cannot be identified by number and street, please provide place references locating the place of injury as accurately as possible. 10. Place of accident or exposure (No. And street, city or town, State and zip code) ' 11. Was place of accident or exposure on em to er's remises? Yes ❑ No ❑ 12. What was the employee doing when injured? (Be specific. If he was using tools or equipment or handling material, name them and tell what he was doing with them.) ' 902 Industrial Way•Lodi,CA 95240•209.3673701 •Fax 209.333.8303 02014 Neil 0.Anderson&Associates.Inc.