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HAZWOPER REFRESHER TRAINING RECEIVED <br />Employee Sign -Off Sheet AUG 1 0 2005 <br />SAN JUAWN COUNTY <br />HAZW OPER REFRESHER TRAINING OFFICE OF EMERGENCY SERVICES <br />Name: ..T�A . _Date: <br />A. Employee has received detail review on Responding to <br />Emergencies in accordance with 1910.120(q)(6)(iii): <br />Identifying, Classifying, and Verifying Chemicals <br />Chemical/Toxicology Terminology and Concerns <br />Environmental and Personal Monitoring <br />Emergency Response Plan (spills/Releases/Accidents) <br />SCCo. Spill Response Plan <br />B. Employee has received detail review of elements contained in <br />1910.120(e): <br />Safety/Emergency Organization at SCCo. (i) <br />Identifying Hazards in the Workplace (ii) <br />Establishing PPE Requirements (iii) <br />Safe Work Practices (minimizing Risks)(iv) <br />Use of Engineering Controls and Equipment (v) <br />Medical Surveillance (symptoms/signs) (vi) <br />Elements of Site Safety and Health plans (vii) <br />C. Employee Participated in Field Exercise <br />Failure of CL2 Flex Line <br />Failure from Bi -gas Tank <br />Hose Leak HCL Railcar <br />Fuse Plug Failure <br />D. Employee received review of <br />Use of Emergency Response Guidebook <br />Review of SCCo. Accident Prevention Plan <br />Specific Responsibilities regarding Emergency Response <br />E. Employee has taken Written Exam. <br />Score: <br />I knowledge having received the training described in this document and I <br />com it to abiding by the sa ety rules and regulations covered. <br />025-05 <br />hi <br />E ployee n ture a <br />Rei -y ompliance Cir /Date <br />