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3� <br /> R <br /> ACCIDENT REPORT FORM <br /> TO: ENVIRONMENTAL, AUDIT, INC. FROM- <br /> 1000_A <br /> ROM1000—A ORTEWAY6 —~,—�^- <br /> PLACENT'IA, CA 9270--7125 <br /> 714/632-8521 <br /> NAME OF I?IJURED OR ILL F't1PLOYEE <br /> SOCIAL SECURITY NUMBER —• <br /> TIMF. OF ACCIDENT <br /> E' TE O <br /> XACTLOCAT'IONraOF ACCIDENT� �— <br /> ��—-- <br /> NARRATIVE DESCRIPTION OF ACCIDENT _ <br /> NATURE OF IT30FYB�DYIINVOLVED)LLiIESs E AS SPE�IFTC A5 PDSSIBLE AND <br /> INCLUDE PAR <br /> LOST TIME: NO YES _: I YES — INDICATE TIME LOSTyy_ <br /> CORRECTIVE ACTION TAKEN <br /> AND WHEN)CORRECTIVE ACTION WHICH REMAINS TO BE TAKEN (BY WHOM <br /> AND <br /> I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, CORREC <br /> ACCURATE. <br /> QATE____� <br /> 4 NAME <br /> SIGNATURE <br /> TITLE <br /> SAB:ARF <br />