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Page 2 Fri Feb 17, 2012 2:56pm Jazz Group, Inc. dba Imperial Truck Wash & Repair Inspection Nr. 314995093 Citation Nr. 01 Item/Group 001 Elemental Analysis - List numerically each descriptive element of the cited Title 8 CCR section in the Elements column. In the Evidence Summary column, specify each item of the evidence found during the Inspection which substantiates the descriptive element (e.g. hazards, operation, equipment, location and/or measurements.) Under Type(s) of Evidence, specify the classification of the evidence described under Evidence Summary. *Observation (OB), Employer Admission (EA), Employer Oral Statement (EOSI, Other Oral Statement (OOS), Employer Written Statement (EWS), Other Written Statement (OWS), Photograph (PH), Business Record (BR), Document (DO), Sample Measurement (SM), Monitoring Measurement (MM), Equipment/Parts/Machinery (EPMI, Other: please specify! Elements Evidence Summary Types of Evidence 342. Reporting Work -Connected Fatalities and Serious Injuries (a) Every employer shall report immediately by Employer did not notify the nearest Cal/OSHA EA, OOS telephone or telegraph to the nearest District District office of a serious injury occurring on or Office of the Division of Occupational Safety and about 1/12/12. Health any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment. EE#1 was burned on both hands and forearms OOS Immediately means as soon as practically possible with hydrofluoric acid. but not longer than 8 hours after the employer knows or with diligent inquiry would have known of the death or serious injury or illness. If the employer can demonstrate that exigent EE#1 was treated at UC Davis Burn Center and OOS circumstances exist, the time frame for the report was admitted from 1/13/12 to 1/15/12. may be made no longer than 24 hours after the incident. Photo (Y/N) ? Comments: Additional Witness Documentation - List the name, address and phone number of each person having percipient information of the factual elements above. After each name list the element numbers from above which the person is able to personally verity. Citation Classification: a. Assuming that an accident or exposure occurs, what are the likely consequences? b. Management Knowledge (check all below that apply) ElActual Management Knowledge Violation. Common Practice at Jobsite x Proximity of Supervisors to Violation x Violation Readily Visible to Anyone Passing By Obligation Anticipated: Forseeable Hazards (i.e. Asbestos Containing Construction Material In Older Buildings Condition Existed Long Enough For Employer Awareness ElConstructive Management Knowledge Accident at Jobsite Previously from Same Violation(s) Special Duty to Inspect -Competent Person at Excavation Employer Received Complaints from Other Employees of Violation Condition Other (please state) OSHA -IB/ IBIRprint(Rev. 9/93)