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State of California <br />DEPARTMENT OF INDUSTRIAL RELATIONS Fatality <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />W.C. Carrier UNINSURED <br />NARRATIVE SUMMARY <br />Establishment Imperial Repair Group, Inc. Inspection 314995093 <br />Name Number <br />Management Manjeet Singh Title Manager <br />Contacted <br />Information on Injured Covered by Workers' Compensation Yes–x– No— <br />Name, Address and Phone Number Occupation <br />Michael Valenzuela Truck Wash <br />Attendant <br />363 S. Airport Road <br />Manteca, CA 95337 <br />510-331-4442 <br />Use additional forms(s) as needed. <br />Witness Name(s) and Title <br />*Check box preceding name if confidentiality is given. <br />Summary <br />On 1/12/12, EE#1 received bums to both hands-and--arms-while washing vehicles with a substance containing <br />hydrofluoric acid. <br />Use additional sheet(s) as needed. <br />Si nature <br />Names and Title(s) Address Phone No. <br />Signed Statement? <br />CSE, IH <br />None <br />Yes No <br />I DM/SR. IH <br />Yes No <br />Yes No <br />Summary <br />On 1/12/12, EE#1 received bums to both hands-and--arms-while washing vehicles with a substance containing <br />hydrofluoric acid. <br />Use additional sheet(s) as needed. <br />Si nature <br />Date <br />Prepared by: <br />CSE, IH <br />Reviewed by: <br />I DM/SR. IH <br />'-dilvarin 1 Ivn knry VIIVJIVy) <br />