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06/04/2008 09:33 FAX 8777958400 INCIDENT REPORT DESA IM 002 <br /> 06/04/2008 06:42 209477016 CHEVRON ##1589 PACE 01/04 <br /> U c-040 t <br /> FaciUty Na. Address S'�I ��'�C £. . _—Page# 1 <br /> 4-1r 4VIOW * loss Investigation Report <br /> Phone No. Company Operated Stores <br /> (9ltype of Lou [] Fre ❑ Criminal Activity General Liability (e.g.custorm incident, <br /> ❑ Fatality ❑ MVA(Employea) SDamage/pill/leak <br /> operty Damage) <br /> El Majorinjury 1771 Business Interruption Equipment Drive off 1❑ Car Wash Damage <br /> ❑ Fhs4Ald/Minor injury ❑ <br /> Drive off tPayment not Breakaway ❑ Near Loss <br /> Received} ❑ Notice of Violation/Cit on <br /> Contral Na- Alert/Bulletin? Yes He Date of Loss Time Loss Occurred � <br /> Every work kdury to im empboo or bac n=ubs reported vwtbb 74 hours after the incident H rift Indderx resthlta Tin d Nor is a me(ol tats such as fee,major WE,erlrnhlal acdifty,ere,..,a raper nalat be <br /> made by phene/fahr/roarl to the Rom Office lncidant Repenlne ftA within a hours Oftor the arclacmt <br /> WOMPLOVER Name: Co:461 Depr ft1 DNr; 38 Org Unit: No. <br /> Wont Lacatioi Address <br /> M EIINPLOYEE Nam- p EPIC ID or SSN: <br /> Employment Steam ❑Regular❑Part Time How long In present Job? Gross Wages/Salmy 5 Per OHour❑Day®Week l7Every 2 Weeks ❑Month <br /> (411NJURY OR ILLNESS INFO an ampicyars prehnlr ? Yes No County; <br /> Whom did Loss/Nonr loss occur? Address(numaer,strm City,state,z1ol: <br /> Specilid ectMly Ow arhhpkhytx was mn8aged In when the Incidrant/riser miss owwed: <br /> All equipment materfals,or donkals she amptoyes was using when the loss/near loss occumW(e.g..the ranine arnpf"a snuck against or which struck employee,the vapor <br /> inhaled or hieatedid avvallrmad;what the employee wea lifrirgi,pulling,00: <br /> Desaiba the speoifio injury or illness leo.,out,strain,fhacnae,skin rash,etc,); <br /> Body part(s)effected Is.g.,beck.Taft wrle;right We,etc,I: <br /> Name and address of HealUh Care Prvhrider(e.g„plrysician or clinic): <br /> Phone Nb,: <br /> Ifhospltalited,name and address of faspitall: Phone No.: <br /> Date of injury or onset of ilInovAMM/DD/YYYY) Time of avant or exposrra: ❑AM ❑ PM <br /> Tare tarhploryee beganvvrnic AM PM Did ernpkriee lose at least one full shift's word No Yes_ ,t st date absent(MM/DDfYYYYi <br /> Has e.coilioyee returned to work? No Yes date returned(MM/ODATM ❑Regular work ®Restricted work ❑No,soil off w urk <br /> Old rmpkgm trio? No Yes dere{MM/DOMrYY} Dm ampbygr noitified or Incident/rme Was; (MM/DO/YYYYJ <br /> Name of person ircidem reported to: Sardel Secvrtry Number(of parson incident reported tDY <br /> Date employee"sled With Workers'Comp Formh;(MM/00/Ytr'YY) <br /> Other wakers Injured/mada ill in this mrk? Yes No TSCA S(cl a4egatlon7 Yes No <br /> Chevron Product Company Marketing Rev.Sept 2005 <br /> CSI�U--NLII <br />