Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 59 of 53 8 ACCID ENTIN CIDE NTL OS S INV ES TI GATI ON WITN ESS STAT EM ENT Doc u m e n t Id e n tif icat ion F R M 012 P age Nu m b e r 1 of 1 Doc u m e n t C r e ation Dat e J a nua r y 1 2013 Im p le m e n tat ion Dat e J a nua r y 1 2013 Da te a nd Tim e o f I nc ide nt L oc a ti on Na me C ompan y Te lephone C e ll ular De sc riptio n of a c c ident Inc ident L oss W he n c ompl e ti ng thi s st a teme nt be sur e to i nc lud e a ll e ve nts and fa c tors th a t l e d to t his ac c identl oss I n c lude a c ti ons t a ke n durin g a nd a fte r Pl e a s e print cle a rl y Attac h a ll ori g inal W it ne ss S tate ments t o the A c c ident I n c ident L oss I nve sti g a ti on re port U se th e ba c k o f this for m for a ddit ional infor mation S tate ment S ig na ture Da te Of fic e Use Onl y Da te Re c e ived R e c e ived B y