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M <br /> 0 <br /> -a <br /> m <br /> OSHA's Form 30OA (Rev 0112004) <br /> Year Department <br /> Summary o Work-Relate juries � Illnesses [f 5.nepaa of Latr co <br /> DocaWrtonW SaHctiand HealHxAmvtntsr.aaion � <br /> r—.pp..•.d 0=m.LMAUG <br /> All establishments covered byPart 1903 musrcomp(ete this Summary page,even fl no work related iliUrfes orillnesses occurred during the year Remember to review the Log ICTI <br /> to verify that the entd0ss are complete and accurate before completing this sun=T.. <br /> Using the Log countthe indrveast entrees you mado preach category.Then write the totals below,maid sure Estah"Ishmertt information fll <br /> had no cases.write"0.' n9 you've added the entries from everypage of the Lag.1t you p <br /> v <br /> Employees,formeremployees.and theirrepresentatives have the right to review the OSHA Form 300 in its entirety They also have funiledaccess to the OSHA Form 301 or c'airasTaD1u 'Q1ta�Lomax Construction Inc. W <br /> its equivalent See 29 CFR Part 1904.35,in OSHA's mcordkeeping ade,torfuriherdetalls on the access provisions for these forms. W <br /> sett 8517-A NorcxQqa Road <br /> city sore NG ZIP 27235 n <br /> D <br /> Total number of Total number of 7bt2tntuaberof 'ibral number of indusayd capaa„(gp,,�rr�jm,rzn/Snnroruu,�vurs) C)w <br /> deaths cascswidt days caseswith3ob otherrecordableelleral C Ontraetors/construction 0 <br /> away rom work D <br /> Y transfer or restri xion cases Standard Iadusnial Gau;fiaflon(SIC),ifknown(eg,3715) <br /> 0 w <br /> 0 0 0 1 5 4 2 D <br /> (G) (M (il (J) Oli <br /> N—LA-6-n Indvarul Gxsificabon(NAICS7,ifkuown(cg.,3362I2) <br /> s- <br /> Total number ofdays away Total number of days ofjob Employment Information(g a dorr'rh,w lnRfg,rctserrlm <br /> from work transfer or or restriction Id"kilvet.a The 6k,dL&pgrr.vdw.) <br /> 0 0 Annualavccagcnnmbcrofgnployccs 117 <br /> (K) (L) Toll hotusworkrd byaII employees tnxtyor 36,413 <br /> ItSign here <br /> Total iturnber of... Knowin lyfal slfyixgthisdocumentmayresultina fine. <br /> (1)Injuries Q (4)poisonings 0 <br /> 0 (`)Hearing loss 0 I certify that I have ned this do t and that to the best ofmy <br /> (2)Skin disorders il knowledge the te,an complete. <br /> —� (6)All other lnesses 0 <br /> (3)Respiratory conditions .. Rich Taylor <br /> Pr_ <br /> a>umnr�...w <br /> 336 992-7000 1-17-13 <br /> Post this Summary gage from February 1 to April 30 of the yoar following the year Covered by the form. <br /> PuClic p.cd.ghnrdanlirtlila.ollacttm.r;�oa�donJC e-.dmatedbavem5n 58 m5w[es pe[repumgtnd¢ding ymeea micw rhetnatmmonc,ccmrhmdsa[ha•Ihe deta�u7¢d,and <br /> �mptetc and.n,%..w the rdled:oa.fi.to�aG..�Pw.man:nouegtdn:d b mp.nd t.w.eollnnG...Ctnlorm.Go..ntesa ttdzplaya a--ay.-did OMS m.lr.t.—baerfyw brave a.y <br /> m+n..n.-alw.tthno eetLnnrn..c onv orfirracpem otthss aatamikaian,eoat>�us DTp. tnClahae.OSR&OM=ofSwUaddAnalyd,.Fo N-36f4MContimttanAvenacNw. <br /> wnsht.yt.n DC46Yla.1)on.tsmdihe.. Fkw f.— dt .nice. <br />