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Referral Report STATE OF CALIFORNIA <br />P DEPART OF INDUSTRIAL RELATIONS <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />MOD Date <br />ID <br />1. Reportipg IDD <br />RR <br />2. Previous Activity? ❑yes <br />❑ No <br />3 (Brien Referral <br />this Number <br />902159185 <br />9506 <br />Enter Type: Number: <br />Referral) <br />4. a. E] <br />b. Est ment Name , <br />5. Employer ID (State's option) <br />Change? <br />& a. ❑ <br />Change? <br />b. Site Address (St , City, State IP) <br />�. <br />�� �� <br />7. City Code <br />& County Code <br />9. Mailing Address (Street, City, State, ZIP <br />Industry & <br />Ownership <br />10. Type of Business <br />J <br />11. Primary SIC <br />12. No. Of Employees <br />13. Ownership (Mark "X" in one box) <br />a. Private Sector b. ❑ Local Government C. <br />❑ State Government d. ❑ Federal Agency/Code L_—��_J <br />Source <br />14. Referred By: <br />��11 <br />15. Date Received _.%a-�S—� y <br />a. ❑ CSE/IH (Within office)/CSE/IH ID ___.._�..._� <br />f. ❑ Consultation <br />b. ❑ Federal OSHA <br />g. ❑ State/Local Government <br />c. >CState OSH <br />h. ❑ Media <br />d. ❑ Discrimination <br />i. ❑ Other (specify) <br />e. ❑ Other Federal Agency/Code <br />16. Source or Contact (Name, Location, Affiliation, Telephone Number) <br />Referral <br />17. a. Safety <br />b. Health <br />Classification <br />(1) ❑ Imminent Danger (2) ❑:Serious3 ❑ Other <br />() <br />(1) El Imminent Danger (2) El Serious (3) 0 Other <br />1& O Migrant Farmworker Camp <br />19. Hazard Description <br />Referral b. Date Letter Sent: a Date Response Due: <br />Action 20. a. ❑ Send Letter <br />22. Inspection Planned? If Yes, If No, <br />❑ Yes No Priority: Reason: <br />21. <br />a. <br />In <br />23. Transfer to (Name): ky_. t(/�..Q/' _(�[_{�[!u.(>24. Transfer Date: _/.-.19, -0Y <br />25. Transfer to (Category): C. ❑ Other Federal Agency/Code <br />a. ❑ Federal OSHA/Reporting ID '_ d. ❑ State/Local Government <br />b. ❑ State OSH/Reporting ID 9506 R ❑ D❑ e. I] Other <br />26. Optional Information <br />Type <br />ID <br />Value <br />Type <br />ID <br />Value <br />27.Total <br />Entries <br />26. Comments: <br />CASE FILE OR TRANSFER COPY <br />CALOSH.90 (1099) <br />