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rntLlMlrvHn r ncrun r yr rrYdJ000 1 nrAL JWLWUr-M 1 <br />STATE OF CALIFORNIA ❑ FATALITY <br />DEPARTMENT OF INDUSTRIAL RELATIONS Date of death: <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />stablishment NSA. of <br />Name Employees <br />Address <br />Street City Zip Code Tel. No. <br />S—State <br />2. Type of <br />L—:local <br />Business- <br />X—:i vt. Indust. <br />. <br />t_J <br />3. Location of <br />Accident <br />Street City Date <br />4. Rep3rted By: <br />Name Title <br />5. Contact at Site: <br />Name Title <br />r, P;arre!Address of Injured Age Occupation <br />7. Acc;dent Description (Specify Mach anism/Candition: Hazardous Substance): <br />S. Location where injured <br />em; 'ogee was moved to: <br />9. Otter Law Enforcement <br />Aggcncies present at site: <br />10. Workers' Compensation Insurance Carrier <br />(N?rne & Address) : [For fatalities only) _ <br />11. Message <br />Received By: <br />13. Referred <br />To: <br />14. Will an investigation <br />ba made? <br />15. District Manager <br />Name/Office <br />Name/Office <br />Date Time <br />Date Time <br />❑ NO_ compiete Reverse <br />Side of form <br />❑ YES. Assigned to: <br />Signature <br />Time <br />Tel. No. <br />C <br />Tel. Wo. <br />12. Date Notified.: <br />Dep. Chief <br />Sol -- <br />Reg. Mgr. <br />Supv.iH — <br />Date Tel. No. <br />. . , ,.A.. Inarl <br />