STATE OF CALIFO 1. CSE/|H 6. Employer 7.

Management Ull Name

Z. npt.

OIVISION OF OCCUPATIONAL SAFETYAND HEALTH l g. l 4. lnsp.

No.

FY

Opening

Present During Inspect

Closing

8. Union Represenl rtives Contacted Narne Title

Labor Union / Phone

Opening lnspect

Present During

Closing

9. Dates:
10. Smalf Employer Relief
11

Subsequent Visits: Ex-MOD Documentation Insurer

19. Evaluation 15. llP Prooram Review IIPP:

Close:

. Ooenina Confer' Tnce

lD

of Safetv & Health Proqram

fl Explain Purpose E CaI/OSHA Progrl tm ! Employee Right! D Inspection Procel Cure fJPoster I Insurance lLog ! PermiWariance I PPE I Consent to Inspd
l
I I

flshow

F+

Date: I Discuss Violatiod s Obs. fJ Closing Date Anqi cipated fl Corrective Actiod
l

12. Exit Conferencel

Reviewed Date: f] vtooet Program Used a. (Required) Program Elements I Responsible Person ! Sanctions/Enforcement I Communication I Inspections ! lnvestigation Procedures D Correction Procedures ! Training b. Record keeping fl lnspection Records I Training Records

E Effective ! Previously

flwritten

tr tr Training tr PPEtrN Housekeeping fl FirstAid tr

Safety Responsibility Employee Participation
20. Adiustment Factors In
%o

Effective

Average

tl n n n

tr

Poor

!
'History

n D n ! n

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

Faith Size n 30 Good fl 40 1-10 I 15Average E 30 11-2s E 0 Poor fl 20 26-60 [ 10 61-100

'Good

! 10 cood D 5 rair fl o Poor

13. Closino Conferdt rce

flEmployer

flViolations ! Citations E Abate/Consult fl Penalties I Posting ! InformalConferlr ce flAppeal ! Fottow-up I Variance

I
I l I i I I

flEmployees

! Written Program Ll rrarnrng n Labeting fl Storage fl MSDS Availabte

I I

16. Hazard Communication Prooram

17. Other Reouirements CaYOSnn Poster Posted CoOe of Safe Practice C Tailgate Meetings ! First Aid Kit

Trained First Aider

I
I

flDiscrimination
'ta

flLos

REASON

I E ! E fl I f] E

f]

2oo Posted - February Emergency Action Plan fire Prevention Plan Respiratory Program LockouVBlockout Safety Process Mgmt. Confined Space Hearing Conservation Bloodborne Pathogens

'

f}
E

18. Cross Jurisdictional Referral Proof of Workers' Comp Insurance Industrial Welfare Commission Poster Posted

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

DIVISION OF OCCUPATIONAL SAFETY AND HEALTH STATE OF 22. Emplovees/Pers0ns lnterviewed During lnspection. Enter name, home address and phone ru.rrnber below.
b. Name/Title: Address: Phone: Phone: d. Name/Title: Address: Phone: Phone:

2of2

Address:

c.
Name/Title: Address:

23. Multi-Employer

Yes LJNo l_l lf yes, obtain the following information on each employer involved.
Employer:
Address: Activities:

a.

Employen
Address: Activities:

I I

Contract Awareness of

Employe/s Work at the Site

I Violation Foreseeable to Employer E Steps Taken by Employer to Protect Employees

lf yes, what specific steps?
Employer Category (Check all that apply) Exposing flCreatipg ! Controlling E Conecting

I fl fl
E

Contract Governing Employer's Work at the Site Awareness of Violation Violation Foreseeable to Employer

Steps Taken by Employer to Protect Employees lf yes, what specific steps? Employer Category (Check all that apply) Exposing n Creating I Controlling ! Conecting

b. Employer:
Address: Activities:

d. Employen
Address: Employer's Work at the Site Activities: Contract Governing Employer's Work at the Site

I Contract f] Awareness
fl

of
to Employer

Violation Foreseea

fl

Steps Taken by lf yes, what specific

to Protect Employees

f] I ! I fl

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

Awareness of Violation Violation Foreseeable to Employer Steps Taken by Employer to Protect Employees lf yes, what specific steps? Employer Category (Check all that apply) Exposing flbreating n Controlling E Correcting

fi

24. Opening and Clo: ng Conference Summary and Additional Comments: [_] Comprehensive LJ Partial

25. Previous Citation {istory: 26. Publications Prov

I Yes Ll No lf yes, attach citation history.

f]Poster
4

I
3.

euide ro catlos A

fJotnerl.
5.

2. o.

27. lf additional shee

are attached, Check this box:

Ll
Cal/OSHA 1A (12l01/00)