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EAU TYPE ALL INFORMATION,,F POSSIBLE . Stara of Calltomia MAIL ORIGINAL O['i 96TLY TO: MAIL 2 COPIES TO: EMPLOYER'S REPORT Dept' Of Industrial Relations Gates !McDonald OSHA Caae- Div. of Labor Statistics 1330 Broadway. Suite 1630 or File No.. OF OCCUPATIONAL P.O. Bax 603 Oakland. CA 94612 San Francisco, CA 94101 4151832.0301 y INJURY OR ILLNESS .. o1cAmX ELITE I X% TYPEWRITER ALIGNMENT GUIDE ,'+CA % % % ELETE Ililorma law requires an employer = to p oyer ro report within fWe days every mdustnai injury or occupational disease winch:(a)Results to lost time oeyond the day of injury. td) requires meatcal treatment other than first aid.PLEASE !VOTE; In aadition. it death resuus or It the In)Ury o•illness. fa) Requires incattent nosorta»an of ire than 24 hours for other than medical observn+on; or (b) resuns 1n loss of any member of the booor to produces anv serious cegme of pttnnanant-- dtqurement,then the nearest district Office at the California Oivision of Occupational b,Safety and manith also must be notified Imtttedistely by telephone or telegraph., is notmcation Is not regtared.howewr-d the m)ury or death resuits from an a=dent on a public street or neghway. ,.FIRM NAME OWENS-BROCKWAY GLASS CONTAINERS tA.POLCYNmJMBER t+LEAeE>JO NOT U29 TNS 2.IAAkErri ADDRESS ft m,aw ails straw:Cav,Z" COLUMN- P.O. Box 30 Tracy, Ca 95378-0030 X209PHONE}u836-8200 CASE NIX 3 LOCATION.IF DIFiERENr FROM MAIL ADDRESS VAwtlaw w,d 91 City.Z3A.LOCAIP) - 14700 W. Schulte Road Tracy, Ca 95375 � � oazz 4A.NATURE OF BUSNESS s.q.,psm"commm.wnwNwq W=W.sswmo.awet.M0. Manufacturers of Gass Containers - S.STATE UNEMPLOYMENT INSURANCE ACCT.NO. 342-6747-6 46.TE OF EMPLOYER: ` TYPE . PRIVATE" STATE' CITY' COUNTY DISTRICT OTHM GOVERNMENT—SPECIFY INplti'!!tY" X � EMPLgYE / i 7.DATE OF BIRTH IMM4X). 1 OGdtPATION E-NOME ADDRESS fNun,aef w1d Strew.C.I.IIPt &A.0""NUMBER 4.SM, v4m. F.mrwa- 10, �ATICi#i(P47"wo tit*.11d lore"al 1m1A at nRk►I It.Socwi SECURITY HUMBER - ,z DEIARTRIE�NT/IH/)AIFMON REGULARLY EMFE4Yl0 12A.GATE OF HIRE(MM-D0.YY) 13.HOURS USUALLY WORKED:HOURS PER DAY 13t DAYS PER WEER 138.TOTAL WEEKLY HOURS t3C.taldw west em"ewe of vow 8 ppp www wogw wugrwgv VA"NOUf+s K d t ...: +s 1iR05S WAGESrSALARY• PEs,,.. HOUR DAY WrEEtt TWO WEEKS MONTH OTHER--SPEctFY X DAVS fit WEEK 's.WHERE DIO ACCIDENT QR EXPOSURE OCCWT iNeunlow wrd 8aaer.CdYF 1 SX COUNTY 1iB.0N EMPLOYER'S PREMISES? - 14700 W. Schulte Rd. , Tracy Ca San Joaquin YE,_. Xo will"MyHOURS; '6 wµAT WAS EMPLOYEE DOING WHEN wuun DT r W"o "am&.edw"V"OHL emhomerr w r WWW r� - � wrrpedyre wa!weq.l - , 61" L-� WIMMY WAGE � i 17 NOw DID THE ACCIDENT OR EXPOSUM OC=W fPMa"eft a prey 1M svewa sae re""InN"" PMraa fire ardwN w,rat a neesrwy,►, w aanaome.dr"W e:r"whw as@Owresd w1a nd,e a>raccowd. LOINR► NAWM OF KfUtt1/ 1fi.OBJECT OR SUBSTANCE THAT DIRECTLY fNUUREO EMvtpyW e.q.. Ins enwyw,w ,§,. .. w M rroeNa urs see►n Crena 01 so arra ne wr wlenq.pwrq,wr. + /!P WWI or..meR musk Ivor. ra I4a or ac+rwr WAO"a !1W&AW we. wo s . G � PART OF SOOT 9A DESCRIBE THE 1NJi1RY OR II.I.fiEBS s.q.,er1r.+rw traAraw am ren.wrr. `_ .. .- 19e,•PART OF BODY AFFECTED s.q.,beCR k11 Neter.ngnt eye,40C. _ satl�e �" 29-NAME AND ADDRESS OF PHrsICLIN fN U ON aria straw.Coy.aP) " - 445 W. Eaton Ave Tracy, Ca 95376 ACCIDWIVIPE >, IF HDSpIT��Aai�ilDtit'fTAI�-IMwev w+a sk+w.c+a nPt � -�� 4- 2- 1A 'Z.DATE OF IWURv OR, - fir .werf.oD.YY1- y EJ,4 23. OF DAY Fm, v� 24.Ota u►aenyaa rrae w I..w ane wk d+w wprr aa.r we 1R,111,/N A.o,a.=,.. YES--0relm rialat _ is.HAS EIAPLOYEI:RETURNED TO WOW? NNI'DDYY) 26.pD EMPLOYEE DIET /� fMM-0GYY1 f7[7'l�TttR "'` No.trill DK wont /Y EArs rwurna� `►r3� YES—Ewe of oa.ae ' f _ca=w, In or pmxl r+ire Gua Patt Coyle ' Plant Nurse SM IREVA) Vn