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iTATE OF GALIFOKAIA DITISIOR 171 El ■Safety 0Co El El 1 0 OF ' 0 C G Em ')ncy Action Plan Fire r-revention Plan Respiratory Program Lockout/Blockout Process Mgmt. nfined Space Hearing Conservation Bloodborne Pathogens Heat illness Prevention Program CSLB License Garment Registration: FEIN or State ER Tax ID FLC License # Other Lic./Cert Name Other Lic./Cert # 14. RecomMng FQ11oE-yg Ins pection REASON 1;! Address: Phone: C. Nameilitle7 18. Cross Jun*sdictional r:.... n Proof of Workers' Comp insurance Aol4f, E3 Industrial Welfare Commission Poster Posted 1� Address, I i� Phone: 23. Multi -Employer Worksite? Yes No If yes, obtain the following information on each employer involved. rage A OT A Exp. Date: Exp. Date: Exp. Date: W MI -6 M.- 22. Employees/Persons Interviewed During Inspection. Enter name, home address and phone number below. a. b. Name/Title, l8fflegl' 1, itlei Address: Phone: Address: Phone: C. Nameilitle7 d. Name/Title- Address: Address, Phone: Phone: 23. Multi -Employer Worksite? Yes No If yes, obtain the following information on each employer involved. a. Employer: c. Employer: Address: Address: Activities: Activities: El Contract Governing Employers Work at the Site ❑ Contract Governing Employer's Work at the Site El Awareness of Violation El Awareness of Violation ❑ Violation Foreseeable to Employer ❑ Violation Foreseeable to Employer ❑ Steps Taken by Employer to Protect Employees ❑ Steps Taken by Employer to Protect Employees If yes, what specific steps? If yes, what specific steps? Employer Category (Check all that apply) Exposing 0 Creating [I Controlling E] Correcting C] Employer Category (Check all that apply) Exposing El Creating 0 Controlling El Correcting El d. Employer: b. Employer: Address: Address: Activities: El Contract Governing Employer's Work at the Site Activities: M Awareness of Violation ❑ Contract Governing Employer's Work at the Site El Violation Foreseeable to Employer El Awareness of Violation 0 Steps Taken by Employer to Protect Employees El Violation Foreseeable to Employer El Steps Taken by Employer to Protect Employees If yes, what specific steps? If yes, what specific steps? Employer Category (Check all that appi Exposing El Creating E Correcting[] Employer Category (Check all that appi A Exposing El Creating [I Controlling Correcting El 24. Opening and Closing Conference Summary and Additional Comments: [] Comprehensive Partial