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Referral Repoli <br />STATE OF CALIFORNIA <br />DEPAhjffki6,;r OF INDUSTRIAL RELATIONS <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />MOD Date <br />7- A.- <br />0 <br />1. Rep ID <br />"iR-g <br />2. Pro-viDus, ActMvIty? <br />if Yes, <br />f7lEntar <br />t <br />E3 Yes 11 I'Jo <br />I- (1,11101gl Numb.. <br />ss this <br />9506F2.1 <br />.r Type. r <br />Type: Number: <br />_Eornments. <br />4. a. F-1 b.tablishment Nair <br />Change? I A,- <br />Employer ID (State's option) <br />R§M!A <br />7. Total <br />Entries <br />o. a. 0 b. Site Add ss (Street, City. State. Z <br />Change? 7 -L4 -X- W. <br />-T <br />Cit", Cade 6. County Code <br />OA6- <br />9. Mailing Address (Street, City, State, zip) <br />Industry & <br />Ownership <br />10. Type of Busine <br />11. Primary SIC 12� No. of Employees <br />-Z 15A -j- <br />13. Ownership (Marx "Y" in one box) <br />a. Private Sector b. C1 Local Government <br />C. 0 State Government d. D.Fedaraf Agency/Code <br />14. Referred By: <br />15 Date Received <br />a. 0 CSEIIH (Within office)/CSE/1H ID L-1 <br />Consultation <br />b. 171 Federal OSHA <br />9 0 Statall-ocal Government <br />a State OSH <br />h. El Media <br />d. 0 Discrimination <br />1. DOther (specify) <br />a. 0 Other Federal Agency/Code <br />16. Source or Contact (Name, Location, Affiliation, Telephone Number) <br />Referral 17. a. Safety b. Health <br />(1) 0 Imminent Danger (2) 0 Serious (3 Other <br />(1) 0 Imminent Ganged <br />18. 0 Migrant Farmworker Camp <br />12. Hazard Description <br />— fta 1— ME —5 <br />Referral b- Date Letter Sent: <br />Action 20. a. 11 Send Letter <br />22. Inspection Planned?It -Yes, <br />Yes 0 No Priority: <br />C] <br />23. Transfer to (Name): <br />25. Transfer to (Category): <br />a. 0 Federal OSHA/Reporting ID <br />b. 0 Stale OSHtReponing ID. 9506 R <br />EJ. DEI <br />26. Optional InlarmAti—' <br />a Date Response Due: <br />Reason: <br />it <br />21. Supervisor(s) Assigned <br />a. I b. <br />-- 24. Transfer Date: <br />c. El Other Federal Agency/Code <br />d. 13 SIAWI-ocal Government <br />a. 0 Other <br />Type <br />ID <br />Value <br />Type <br />ID <br />Value <br />_Eornments. <br />7. Total <br />Entries <br />#Y <br />