CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Nominator:

Name:
Agency:
Address:
City, Zip Code:
Work Phone:
Fax:
Email Address:

Nominating Local Section:

Nominee:

Name:
Agency:
Address:
City, Zip Code:
Work Phone:
Fax:
Email Address:

NominatingLocal Section:

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Small (1-25 Employees)
Medium (26-75 Employees)
Large (76 or greater)

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Size Category

Checklist of Awards Criteria: You must include all of the following to be eligible for the award.

At least one person from agency must be a CWEA member; proof of membership required.

Copies of OSHA Form 300A Summary of Work Related Injuries and Illnesses for Year 20142015.

The nomination packet submitted to the local sections must include three (3) copies.

Nominator Instructions:

  1. All nominations must use the attached form. Other formats will not be accepted.
  2. Provide a physical index tab for all referenced attachments and supplemental documents so that they can be easily recognized and located. Submit only the requested documentation.
  3. Submitted materials will not be returned.
  4. Submit this nomination form and all attachments in each size category (small, medium large) to your local section awards chair/contact by the awards deadline given below:

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Central San Joaquin (CSJ)

Deadline:November 1, 2015

Awards Chair: Thomas Adams

5607 West Jensen Ave.

Fresno, CA 93706

, 559-621-5140

Colorado Basin Section (CORBS)

Deadline:November 13, 2015

Awards Chair: Mark Graham

68380 Moonlight Dr.

Cathedral City, CA 92234

, 760-328-6896

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Desert and Mountain (DAMS)

Deadline:October 2, 2015

Awards Chair: Kim Booth, BBRWA

121 Palomino Dr. P.O. Box 517

Big Bear City, CA 92314

, 909-584-4018

Golden Empire Section (GES)

Deadline:Contact local section

Awards Chair: Mike Popichak

PO Box 9956

Bakersfield, CA93389

, 661-979-3276

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Los Angeles Basin Section (LABS)

Deadline:November 20, 2015

Awards Chair: Miluska Propersi, RMC Water and Environment

2400 Broadway Suite 300

Santa Monica, CA 90404
,

310-566-6460

Monterey Bay Section

Deadline:October 1, 2015

Awards Chair: Jackie McCloud, City of Watsonville

500 Clearwater Ln.

Wastonville, CA 95076

, 831-768-3172

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CWEA Nomination Form

Collection Systems Committee
Collection System of the Year

North Coast Section (NCS)

Deadline:Contact local section

Awards Chair: T.K. Williams

2752 Hillcrest Dr.

Eureka, CA , 323-257-7749

Northern Sacramento Valley (NSV)

Deadline:October 30, 2015

Awards Chair: Nolan Randall

111 Main St.

Palm Springs, CA 99999

, 530-229-3341

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CWEA Nomination Form

Collection Systems Committee
Collection System of the Year

Northern San Joaquin Section (NSJ)

Deadline:October 30, 2015

Awards Chair: Bonnie Dennedy

17103 West Bethany Road

Mountain House, CA 95391

,
209-836-3351

Redwood Empire Section (RES)

Deadline:Contact local section

Awards Chair: Rodrigo Montanez

4539 Crimson Clover Dr.

Fairfield, CA 94534

, 707-258-6083

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CWEA Nomination Form

Collection Systems Committee
Collection System of the Year

Sacramento Area Section (SAC)

Deadline:Contact local section

Awards Chair: Debi Lewis

3321 Power Inn Road STE 300

Sacramento, CA 95826

,
916-418-8293

San Diego Section (SD)

Deadline:November 20, 2015

Awards Chair: Steve Jepsen, DUDEK
605 Third Street

Encinitas, CA 92024

, 760-415-4332

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CWEA Nomination Form

Collection Systems Committee
Collection System of the Year

San Francisco Bay (SFB)

Deadline:October 15, 2015

Awards Chair: Steve Dominguez, Veolia

3000 Airport Rd.

Rio Vista, CA 94571

,
707-374-2633

Santa Ana River Basin (SARBS)

Deadline:November 6, 2015

Awards Chair: Megan Yoo Schneider,
Moulton Niguel Water District

27500 La Paz Road

Laguna Niguel, CA 92677

, 949-448-4020

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CWEA Nomination Form

Collection Systems Committee
Collection System of the Year

Santa Clara Valley Section (SCV)

Deadline:Contact local section

Awards Chair: Sid Nash

1567 Kooser Road

San Jose, CA 95118

, 408-515-3084

Sierra Section

Deadline:November 5, 2015

Awards Chair: Evy Henkel

PO Box 1609

Truckee, CA 96160

,
530-277-4887

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Tri-Counties Section

Deadline:Contact local section

Awards Chair: Thomas Welch

520 E. Yanonali

Santa Barbara, CA 93103
,
805-568-1002

Go to myCWEA.org and click on Local Section on the menu to learn more about each local section.

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CWEA Nomination Form

Plant Safety Committee

Plant Safety Award
Small | Medium | Large WWPT’S

Local Section Instructions

No more than one nomination for the Plant Safety Award may be submitted by each Local Section as their Local Section Winner. Submittal of more than one nomination in each category will invalidate that Local Section’s entry. Three (3) copies to be submitted for each.

(Applications and supplemental documentation submitted electronically must have the questions “Hyper-linked” to the answers and the answers hyper-linked back to the application.)

  1. The CWEA Plant SafetyAwards are coordinated by the CWEA Plant SafetyCommittee. The team is comprised of the Awards Subcommittee Chair, Committee Chair, and equal representation from the Northern and Southern regions.
  2. The committee will evaluate all nominees for this award.
  3. All award nominees will be notified of their award status prior to the CWEA Annual
    Conference.
  4. Send State Award Nominations to CWEA Awards program, 7677 Oakport Street, Suite 600, Oakland, CA 94621 or email to as a pdf. Other file formats will not be accepted.
  5. All State awards must be received by FRIDAY, January 8, 2016. Postmarks will not be accepted.

Questions:

John Isaac Chadwell, CWEA State Safety Awards Program Coordinator,r (949) 540-6800 ext. 114.

I.GENERAL INFORMATION:

A.Name of Plant:

Address:

B.What is the total number of PLANT employees represented by the information in application? Include all employees (regular, part time, etc.) who are required to be included on the OSHA 300A log.

(DO NOT INCLUDE COLLECTIONS PERSONNEL - WWTP staff only)

  1. Person responsible for the safety program: Phone:

Title: Email:

II.SAFETY RECORD:

  1. Recordable Incidents:
  2. What is the total number of Recordable Incidents for the Wastewater Plant (do not include Collections) for the prior year (01/01/14 – 12/31/15)? (Total # of incidents)
  1. What is the total number of Recordable Incidents for the Wastewater Plant (do not include Collections) for the current year (01/01/15 – 06/30/15)? (Total # of incidents)
  1. Lost Time Incidents:
  2. What is the total number of Lost Time days for the Wastewater Plant (do not include Collections) for the prior year (01/01/14-12/31/15)?

(Days)

  1. What is the total number of Lost Time days for the Wastewater Plant (do not include Collections) for the current year (01/01/15-06/30/15)? (Days)

C.Include a copy of the CalOSHA 300A Summary Forms for both time periods (2014 and 2015) and line through any employee(s) who is not represented by this application (e.g. collections).

D.Has your agency reported a serious injury or illness to CalOSHA during the period of January 2014 through June, 2015 Yes No

  1. SAFETY PROGRAM:
  1. Incident Investigation:
  2. What criteria (i.e. under what conditions) does your agency use to conduct an in-depth, formal incident investigation?
  1. Provide a detailed description of the Incident Investigation procedure, including any resources used to facilitate an immediate and thorough investigation.

B.Communication and Training:

1. How do you communicate safety to your employees? (Include documentation
that supports your program).

2. How do your employees communicate safety to you? (Include documentation that supports your program).

3.What method(s) is used so that employees can report unsafe conditions anonymously?

  1. Provide a detailed description of your agency’s New Employee Safety Orientation program. Include any resources used to facilitate this program.
  2. Provide a detailed description of how initial and refresher safety training is managed (i.e. How it is scheduled and tracked for compliance?) Include any resources used to manage safety training requirements.
  3. Provide the 2014or 2015 documentation of the following training topics:

Confined Space Entry & Rescue

Fire Extinguishers
Bloodborne Pathogens
Respiratory Protection

  1. Provide at least one completed example of how a safety tailgate training topic is documented.

C.Safety Inspections:

  1. Provide a detailed description of your agency’s scheduled safety inspections. Include WHO, WHAT, WHEN and HOW in this description.
  1. Describe in detail the procedure for managing unsafe conditions (documenting, tracking, and correcting).
  1. Check the following inspections that are performed and note the frequency they are performed. If not applicable to your agency, note the reason why. Provide completed inspection documentation for at least 3 of the items below.

Equipment: Frequency Explain if NA:

Fire Extinguishers (§6151) NA:

Eyewash/showers (§5162)NA:

Forklifts (§3668)NA:

Crane Inspections (§5031)NA:

Ladder Inspections (§3276)NA:

Smoke detectors (NFPA 820)NA:

Fire alarms (NFPA 820)NA:

Fall protection equipment (§1670; §8414)NA:

Confined Space Equipment (§1604.26) NA:

Personal Protective Equipment (§3380-§3386)NA:

Emergency Respirators (SCBA) (§5144)NA:

First Aid Supplies (§3400)NA:

  1. Hazardous Materials Spill Response Capabilities and Training: Provide a copy of the following documents from the most current Hazardous Materials Emergency Response Plan (Business Plan):
  2. Emergency Response Plan Guidelines
  3. Emergency Training Plan

E.Emergency Action Planning:

  1. Provide a detailed description of your agency’s Evacuation procedures including any resources used to facilitate this program.
  1. Provide a detailed description of your agency’s Shelter-in-Place procedures including any resources used to facilitate this program.
  1. How often does your agency perform an Emergency Evacuation Drill? Provide documentation to support this.
  1. How often does your agency perform a Shelter-in-Place Drill? Provide documentation to support this.

F.Lockout/Tagout:

  1. Provide examples of equipment lockout procedures for five pieces of equipment (or groups of equipment) at your facility.
  1. Has your agency conducted an arc-flash analysis in accordance with the NFPA70E/NEC 2012?

Yes: Year this was conducted:______
No

3. Provide documentation demonstrating that your agency conducts annual interviews with Lockout/Tagout authorized employees in order to evaluate the Lockout/Tagout program.

IV.EXCEPTIONAL SAFETY PROGRAMS & PRACTICES:

Provide any exceptional (above and beyond) and/or unique safety programs or practices that you believe demonstrate that your agency has an “award-winning” safety program. Provide documentation and/or resources to support how these programs/practices are implemented and performed.

V.SAFETY CULTURE:

Complete the following to demonstrate how your agency encourages and promotes an award-winning safety culture at your agency:

  1. Are employees encouraged, including monetary support, to attend professional organizations that enhance their safety awareness and knowledge?

No:

Yes:

List the organizations and provide the work groups that participate and attend:

  1. Describe any safety incentive programs your agency uses to encourage safety awareness, to increase participation in the safety program, and to reduce worker injuries and illnesses.

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