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10 0 <br />SIA I E 1,F GAILIFORAIIA ArZALTA- <br />1. CSE/I H G0994 1 2. Rp� No -034 '1 3. FY 2012 F <br />4. Insp. No. 314995093 .15 Region 2 <br />6. Employer Legal Entity Name: Jazz Group, Inc. Imperial Repair Group, Inc. <br />DBA: Imperial Truck Wash & Repair Employer email address: <br />7. Management Officials Contact•ed Present During <br />Name Title Opening <br />Manjeet Singh Manager Yes <br />8. Union Representatives Contacted: <br />Name Title <br />Non -Union <br />District 4 <br />Inspect Closing <br />Yes Yes <br />Present During <br />Opening Inspect Closing <br />9. Dates: 02102/12 <br />Subsequent Visits.- Yes <br />Close: <br />10. Small Employer Relief <br />Ex -MOD <br />Documentation Insurer <br />NONE <br />11. Opening Conference <br />15. UP eLpgram Rev <br />19. Evaluation of Safety <br />& Health Program <br />Ili <br />Show Dr. <br />r. <br />Imp: <br />ra <br />Ave9 <br />e Poor <br />Explain Purpose <br />El Written <br />Safety Responsibility <br />1:1 <br />Cal/OSHA Program <br />1Effective <br />71 <br />Employee Participation <br />Employee RightsEl <br />Previously Reviewed <br />Training <br />Q <br />Inspection Procedure <br />Date: <br />PPE <br />F� <br />Poster <br />Housekeeping <br />insurance <br />C3 Model Program Used <br />First Aid <br />Log <br />a. (Required) Program Elements <br />I <br />i <br />Permit/Variance <br />C1 Responsible Person <br />20. AdOALrgent Factors In <br />% <br />*History <br />PPE <br />n Sanctions/Enforcement <br />•*Good Faith <br />Size <br />Consent to Inspect <br />El Communication <br />rl Inspections <br />El 30 Good <br />El IS Average <br />0401-10 <br />30 11-25 <br />0 10 Good <br />6 Fair <br />investigabon Procedures <br />0 0 Poor <br />El 20 26-60 <br />IR 0 Poor <br />F] •Correction •Procedures <br />01061-100 <br />12. Exit ConfeLence <br />F1 Training <br />00verI00 <br />Date: 02/02112 <br />b. Record keeping <br />Does not apply to penafties for accident related serious, <br />Discuss Violations Obs. <br />El Inspection Records <br />willful, repeat, or a serious <br />violation with lack of an operative <br />i El Training Records <br />Injury & Illness Prevention <br />Program. <br />Corrective Action <br />Employer <br />Employees <br />Violations <br />Citations <br />Abate/Consult <br />► Penalties <br />Posting <br />faftau"'Z <br />Appeal <br />Follow-up <br />Variance <br />Discrimination <br />16. Hazard Communication Prot <br />El Written Program <br />El Training <br />❑ Labeling otuc' <br />❑ Storage <br />El MSDS Available <br />17. Qther Requirements <br />FCal/OSHA Poster Posted <br />Code of Safe Practice <br />F-1 Tailgate Meetings <br />El First Aid Kit <br />El Trained First Alder <br />n Log 200 <br />El Posted - February <br />Corporation/Partnership/Sole Owner/LLC (circle one) <br />Send mail to: <br />Business Address: <br />Phone No. Fax No. <br />Main Office Address: <br />Phone No. Fax No. <br />Owner or Officer of Corporation, etc. <br />Location of Records: <br />Business License # Exp. Date: <br />WE COI -40M <br />