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Referral Report <br />STX"' OF C.AV-I;:0RWlA <br />DEPART& OF INDUSTRIAL RE <br />LATRON-q <br />DIVISION 0*F- OC-CUP-aTIONAL SAFETY AND HEALTH <br />MOD Date 11. i5ovnir r I`2Previous Activity? �ra -, I W <br />r <br />-z It �22. F, 4a=_ <br />TYoe: Numba. i;sIarrall <br />s this <br />a, F - <br />j L. EVreblishmeni Nlam_ a. <br />Change? Emoloyar IE) (Slate's oation) <br />a, b. Site A ass (Sire.3% City Slat- 71p) <br />On IV * 'Cit) County Code <br />angs? <br />A 7-7 <br />9. Mailing Andress (5tresi, City. Stale, ZIP) <br />Industry & 10. !&of Busin— <br />Ownership 11. Primary sic 12� Na of Employees <br />E; L <br />13, O%vjs . nip (Maa.-T" in once box) <br />a. Private Sector b. LGovernmentLocalGovernmentc. D Staig Guvernmeni d. 0 - Federal Agency/Coos <br />Source. 14. Referred By: 15. Date Received <br />a. 0 CSEIIH (Within offire)ICSEIIH ID Consultation <br />b. 13 Federal OSHA9. 1i Stals/Local Government <br />c. State OSH h. 0 Media <br />d. D Discrimination I. C1 Dther (specify) <br />a. 0 Other Federal Agency/Code <br />F <br />16. Source or Contact (Name, Location, Affiliation, -telephone Number) <br />IT P. Safety <br />Referral sit, <br />b. Health <br />Classification: <br />(1) 0 Imminent Danger (2) F1 Serious Other (1) 0 Imminent Danoer (21) Serious (3LjD4h.r <br />.. .. .. 18. 0 Migrant Farmworkgr Camp <br />19. Hazard Description <br />M <br />Referral b. Date Letter Sent c. Date Response Due: --T2 —,., I <br />Action 20. a. C1 Send Letter 1. SupervisMs) Assigned <br />a. b. <br />22. Inspection Planned? It <br />If No, <br />0 Yes L-] NoReason: <br />Priority: <br />22. Transfer io (Name): <br />24. Transfer Date: <br />25. Transfer to <br />(Category): a D Other Federal Acency/Code <br />a. El Federal OSHAIRsporting 11) <br />d- 0 State/Local Gcrjgrnmeni <br />b. 0 Slats 0SH/Reporling ID 95os R 0. D El e. 0 Other <br />25. Optional Information' <br />Type <br />10 <br />Value <br />Type <br />10 <br />Value <br />Comments: <br />27. 7btal <br />Entries <br />CALOSH-90 (100) <br />