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rnCLuvtirmAn r ncr mn 1 ur 1rVUU.'1 s ntwB. A"luCry i <br />STATE OF CALIFORNIA ❑ FATALITY <br />DEPARTMENT OF INDUSTRIAL RELATIONS Date of death: <br />91VISION OF OCCUPATIONAL SAFETY AND HEALTH <br />® ,stablishment NO. of <br />Name Employees <br />Address i <br />Street City Zip Coc(e Tei. No. <br />S—State <br />2. Type of L—local <br />Business• X--Pvt. Indust. <br />3. Location of <br />Accident <br />•Street City Date Time <br />a. Reported By: C 1 <br />Name Title Tel. No. <br />5. Contact at Site: f <br />Name Title <br />6. Nla.me!Address of Injured Age Occupation <br />7. ; .c6dent Description (Snecifv Mechanism/C-sndition: hazardous Substance): <br />S. Location where injured <br />em, 'oyee was moved to: <br />9. Other Law Enforcement <br />A.g;;ncies present at site: <br />10. Workers' Compensation insurance Carrier <br />(N3rne & Address) : (For fatalities only) _ <br />11. Message <br />Received By: -- -- <br />Name/Office Date Time <br />13. Referred <br />70: <br />Name/Office Date Time <br />14, Will an investigation <br />be made? ❑ NO. Complete Reverse <br />Side of form <br />® YES. Assigned to: <br />15. District Manager <br />Signature <br />Date <br />Tea. No. <br />fninrr, <br />12. Date Notified: <br />Dep. Chief <br />601 <br />Reg. Mgr. <br />Supv. IH <br />Tel. No. <br />.. �.�o4.w • w 71.Jv 1CRFi <br />