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11 -f <br />MEMEMT46r, <br />MOD Date 1. ReporliRg <br />i17—®2`'' !,., 1 9506A <br />4. a. 0 , b. EVablishment Name <br />Change? I % - <br />b. Site Add (Street, City, <br />Change? <br />9. Mailing Address treat, City, State, Zip) <br />Industry & 10. Type of Business <br />Ownership11. Primary SIC 12. No. of Employees_ <br />54 <br />13. Omers i i if I (Mark �"r 11, one �b.,) <br />a.. Private Sector b. El Local Government c. 11 State Go Verriment d. <br />Source by/Co 0: <br />14. Referred By: <br />STATE OF CALIFORNIA <br />I <br />a. 0 CSE/IH (Within office)/CSEIIH ID <br />DEPA, OF INDUSTRIAL RELATIONS <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />2, Previous Activity? <br />It Yes, <br />C01 Yes 11 No <br />State OSH <br />Referral <br />3. Referral Number <br />Enter Type: <br />Number: <br />L 11 Other (specify) <br />WIdeni'Ifies this <br />his <br />1. <br />I, at)m` <br />4 <br />5- roploye, <br />5. Employer ID (State's —.0-1) <br />ZIP) <br />Code --TII- CountyCodeCode <br />Industry & 10. Type of Business <br />Ownership11. Primary SIC 12. No. of Employees_ <br />54 <br />13. Omers i i if I (Mark �"r 11, one �b.,) <br />a.. Private Sector b. El Local Government c. 11 State Go Verriment d. <br />Source by/Co 0: <br />Other Federal Agency/Code L-,--L--Li <br />16. Source or Contact (Name, Location, AffiliaBion, Telephone Number) <br />Referral.; <br />17. a. Safety <br />Classification.'. * Health <br />11 Imminent "anger (2) El Serious (3)imminent <br />18. El Migrant FarMWOrker Camp <br />19. Hazard Description <br />Referral <br />a, <br />Action 20. a D Send Letter <br />2& Transfer to (Name): <br />25. Transfer to (Category): <br />a- 11 Federal OSHAIReporlting ID <br />L <br />b. 0 State OSH/`Repo rting ID, 9506 R 0 D 0 <br />21. Supervisoqs) Assigned <br />a. I b. <br />Reason: <br />24. Transfer Date: <br />c. 11 Other Federal Agency/Code <br />d. D State/Local Government <br />G, 0 Other <br />14. Referred By: <br />15. Date Received <br />a. 0 CSE/IH (Within office)/CSEIIH ID <br />f. 0 Consultation <br />b. 0 Federal OSHA <br />9 D State/Local Government <br />State OSH <br />h. 11 Media <br />d. iscrimination <br />L 11 Other (specify) <br />Other Federal Agency/Code L-,--L--Li <br />16. Source or Contact (Name, Location, AffiliaBion, Telephone Number) <br />Referral.; <br />17. a. Safety <br />Classification.'. * Health <br />11 Imminent "anger (2) El Serious (3)imminent <br />18. El Migrant FarMWOrker Camp <br />19. Hazard Description <br />Referral <br />a, <br />Action 20. a D Send Letter <br />2& Transfer to (Name): <br />25. Transfer to (Category): <br />a- 11 Federal OSHAIReporlting ID <br />L <br />b. 0 State OSH/`Repo rting ID, 9506 R 0 D 0 <br />21. Supervisoqs) Assigned <br />a. I b. <br />Reason: <br />24. Transfer Date: <br />c. 11 Other Federal Agency/Code <br />d. D State/Local Government <br />G, 0 Other <br />