STATE OF CALIFO OIVISION OF OCCUPATIONAL SAFETYAND HEALTH1. CSE/|H Z. npt. No. l g. FY l 4. lnsp.6. Employer7. Management UllName

Present DuringOpening Inspect Closing

8. Union RepresenlNarne

rtives ContactedTitle Labor Union / Phone

Present DuringOpening lnspect Closing

9. Dates: Subsequent Visits: Close:

10. Smalf Employer Relief Ex-MOD Documentation Insurer

11 . Ooenina Confer'flshow lD

fl Explain PurposeE CaI/OSHA Progrl! Employee Right!D Inspection ProcelfJPoster l

I Insurance I

lLog I

! PermiWariance j

I PPEI Consent to Inspd

Tnce

tm

Cure

F+

15. llP Prooram ReviewIIPP:flwrittenE Effective! Previously ReviewedDate:f] vtooet Program Useda. (Required) Program ElementsI Responsible Person! Sanctions/EnforcementI CommunicationI Inspections! lnvestigation ProceduresD Correction Procedures! Trainingb. Record keepingfl lnspection RecordsI Training Records

19. Evaluation of Safetv & Health ProqramEffective Average

Safety Responsibility tr trEmployee Participation tr tlTraining tr nPPEtrNHousekeeping fl nFirstAid tr n

PoornDn!n!

20. Adiustment Factors In %o

'Good Faith Sizen 30 Good fl 40 1-10I 15Average E 30 11-2sE 0 Poor fl 20 26-60

[ 10 61-100

'History! 10 coodD 5 rairfl o Poor

fl 0 Over 100'Does not apply to penalties for accident related serious,willful, repeat, or a serious violation with lack of an operativeIniury & lllness Prevention Proqram.

12. Exit ConferencelDate: l

I Discuss ViolatiodfJ Closing Date Anqi

fl Corrective Actiod

s Obs.cipated

13. Closino ConferdtflEmployerflEmployees I

flViolations I

! Citations I

E Abate/Consult l

fl Penalties I

I Posting i

! InformalConferlrflAppeal I

! Fottow-up I

I Variance I

flDiscrimination I

rce

ce

16. Hazard Communication Prooram! Written ProgramLl rrarnrngn Labetingfl Storagefl MSDS Availabte

21. CommentslNotes

17. Other ReouirementsI CaYOSnn Poster PostedI CoOe of Safe PracticeC Tailgate Meetings! First Aid KitI Trained First AiderflLos 2oof] Posted - FebruaryI Emergency Action Plan 'E fire Prevention Plan! Respiratory ProgramE LockouVBlockoutfl Safety Process Mgmt.I Confined Spacef] Hearing ConservationE Bloodborne Pathogens

'ta

REASON

18. Cross Jurisdictional Referral

f} Proof of Workers' CompInsurance

E Industrial Welfare CommissionPoster Posted

Ca|/OSHA 1A (12/01/00)

STATE OF DIVISION OF OCCUPATIONAL SAFETY AND HEALTH 2of222. Emplovees/Pers0ns lnterviewed During lnspection. Enter name, home address and phone ru.rrnber below.

b.Name/Title:

Address: Address:

Phone: Phone:

c.Name/Title:

d.Name/Title:

Address: Address:

Phone: Phone:

23. Multi-Employer Yes LJNo l_l lf yes, obtain the following information on each employer involved.

a. Employen Employer:

Address:Address:

Activities: Activities:I Contract Employe/s Work at the Site E Contract Governing Employer's Work at the Site

I Awareness of Violation

fl Violation Foreseeable to Employer

I Awareness of

I Violation Foreseeable to Employer

E Steps Taken by Employer to Protect Employees fl Steps Taken by Employer to Protect Employeeslf yes, what specific steps? lf yes, what specific steps?Employer Category (Check all that apply)

Exposing flCreatipg ! Controlling E Conecting EEmployer Category (Check all that apply)

Exposing n Creating I Controlling ! Conecting E

b. Employer:

Address:

Activities:

d. Employen

Address:

Activities:I Contract Employer's Work at the Site f] Contract Governing Employer's Work at the Site

I Awareness of Violation

! Violation Foreseeable to Employer

f] Awareness of

fl Violation Foreseea to Employer

fl Steps Taken by to Protect Employees I Steps Taken by Employer to Protect Employeeslf yes, what specific lf yes, what specific steps?Employer Category (Check all that apply)

Exposing fl Creatifrg fl Controlling fl Conecting flEmployer Category (Check all that apply)

Exposing flbreating n Controlling E Correcting fi24. Opening and Clo: ng Conference Summary and Additional Comments: [_] Comprehensive LJ Partial

25. Previous Citation {istory: I Yes Ll No lf yes, attach citation history.

26. Publications Prov

I euide ro catlos

3.

A f]Poster fJotnerl. 2.

o.4 5.

27. lf additional shee are attached, Check this box: Ll

Cal/OSHA 1A (12l01/00)