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PRELIMINARY REPORT OF INDUSTRIAL ACCIDENT <br />STATE OF CALIFORNIA Q FATAL)TY <br />DEPARTMENT OF INDUSTRIAL RELATIONS D.a.to of death: <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />1. establishment Na. Qaf <br />Name <br />lElmptoyees . <br />Address C <br />Street City Zip Locie Tel. No. <br />2. Type of IL—Local Business <br />X—ftt. Indust <br />3. Location of <br />Accident <br />a. Permted By: <br />5. Contact at Site: <br />Street City Date Time <br />Name — Title Tel. -No. <br />Name Title <br />5. Name!Address of Injured _ Awe Occupation <br />i. A.c4dent Description (Specify Mechanism/Condition.'Hazardous Substance): <br />8. Location where injured <br />em; `ogee was moved to: <br />9. Other Law Enforcement <br />A.g,;ncies present at site: <br />10. Workers' Compensation Insurance Carrier <br />(N?me & Address). [Forfatalities only) _ <br />11. Message <br />Received By: <br />Name/Off':;e Gate Time <br />13. Referred <br />To. <br />Name/Office Date Time <br />14. 'Will an investigation <br />nv matte? <br />15. District Manager <br />® NO. Complete Reverse <br />Side of form <br />YES. Assigned to: <br />Tel. No. <br />I niaor, <br />12. Date Notified: <br />Dep. Chief <br />801 <br />Reg. Mgr. <br />Supv.lH <br />Signature Date Tel. No. <br />C7 <br />