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| Establishment
Name: |
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| Site
Street 1: |
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| Site
Street 2: |
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| City:
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State: |
MI |
Zip
Code: |
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| Site
Phone: |
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-
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Site
Fax: |
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-
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MAILING ADDRESS (If different from site address) |
| Street
1: |
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| Street
2: |
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| City: |
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State:
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Zip
Code: |
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| Mail
Phone: |
-
-
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Mail
Fax: |
-
-
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| Management
Official: |
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| Telephone:
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-
-
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| Type
of Business: |
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| HAZARD
DESCRIPTION/LOCATION. Describe briefly the hazards you believe exist.
Include the approximate number of employees exposed to or threatened
by each hazard. Specify the particular building or work site where
the alleged violation exists. |
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| The
undersigned believes that a violation of an occupational safety or
health standard exists which is a job safety or health hazard at the
establishment named on this form. |
| Complainant
Name: |
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| Complainant
Telephone: |
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-
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| Must
include address or email in order to process the complaint |
| COMPLAINANT
ADDRESS |
| Street
1: |
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| Street
2: |
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| City: |
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State:
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Zip
Code: |
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Email: |
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| If
you are an authorized representative of employees affected by this
complaint, please state the name of the organization that you represent
and your title. |
| Organization
Name: |
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| Your
Title: |
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| The
Department of Labor & Economic Growth will not discriminate against
any individual or group because of race, sex, religion, age, national
origin, color, marital status, political beliefs or disability. If
you need help with reading, writing, hearing, etc., under the American
with Disabilities Act, you may make your needs known to this agency.
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