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'A 4 <br />0 <br />0 <br />R9PDrt pat" <br />STATE OF CALIFORNIAReferral <br />DFPART41r OF INDUSTRIAL <br />RELATION'S <br />DIVISION OF OCCUPATIONAL SAF—ETY AND HEAL H <br />MOD Date 1. Reporting ID 12. Pr--VjrU5,A.(-jjvjjy�,7 <br />8 'ev <br />-Yes <br />Z If ),as, <br />01 I3. Referral Number <br />(identifies <br />Enter Type: Number: <br />Referral) <br />Q. a. 0 1: stab4shment Name <br />A, <br />Change? <br />5� Employer ID (State's option) <br />a. 0 b. Site Ado ass (Street, City, Stat. 71p) <br />Change? <br />7. City Gode e. County Gode <br />3. ling Address (Street. City, State, ZAP) <br />Industry <br />10. 1 pe of Business <br />a <br />OwnershipL <br />'11. Primary SIC 12. No, of Employees <br />13. Ow sh 4 <br />livisrh -X- in one boy) <br />ip (I <br />Sect <br />a. jjCPri1vPate Sector b. 0 Local Government C. <br />--------------------------------------------------------------- <br />13 State Government 1 O. Federal igencylCo <br />So . urce. <br />14. Referred By: <br />15. Date Received <br />a. 0 CSEIIH (Within OfficaVIOSE/11-1 ID L j <br />a. 13 Consultation <br />b. n Federal OSHA <br />9- 0 State/Local Government <br />State OSH <br />h. 0 Media <br />d. Discrimination <br />1. 0 Other (specity) <br />8. U Other Federal AggincylCode <br />16. Source or Contact (Name, Location, Affiliation. Telephone Number) <br />Referra <br />It. a—Safety <br />Plasalti ation Imminent <br />b. Health <br />mminent Danger(2) 0 Serious (3 'Other 0) 0 Imminent Daner <br />g (2) 0 Serious <br />18. 0 Migrant Farm Camp <br />IS. Hazard Description <br />Halarrel <br />Action 20. a. 0 Send Letter b. Date Letter Sent: a Date Response <br />22. Inspection Planned, <br />Yes No Priority: <br />23. Transfer to (Name): <br />Z.- <br />25. Transfer to (Category):. <br />& D federal OSHA/Reponing ID <br />b. 0 State OSH/Reponing ID, 95o6 RE] D El <br />26. Optional Information' <br />R a 1�61 N <br />21. Supervisor(s)Assigned <br />a. fb. <br />It No, <br />Reason: <br />— -- 24 -Transfer Date: <br />c. 0 Other Federal Agency/Code <br />d. 11 Slate/Local Government <br />a. 0 Other <br />aa��, <br />