{mfg-v . .3.) - M- .hur Inspection Report Tue Apr 14, 2015 12:20:25 PM RID CSHO ID Supervisor ID Inspection Number Optional Report Number Case Closed Date 0950615 L5223 J6921 1055195 036-15 Establishment Name Blue Apron Inc. Doing Business As (DBA) Establishment Private Sector Type of Business Corporation 311991 Owner Name Primary NAICS Site Address 3151 Regatta Blvd. Site Phone Extn Site FAX C60 RICHMOND, CA, 94804 Business Address 3151 Regatta Blvd. Business Phone Business FAX C60 RICHMOND, CA, 94804 Mailing Address 3151 Regatta Blvd. E-mail Mobile Phone C60 RICHMOND, CA, 94804 Site Activity Food preparation NAICS Inspected 452910 Days on Site 1 Federal EIN DUNS Temporary or Fixed Site? Fixed Site Entry 13-APR-2015 11:30 AM First Closing Conference Opening Conference 13-APR-201 5 12:00 PM Second Closing Conference Walkaround 13-APR-2015 12:30 PM I 1 Exit 5 02:45 PM Inspection Initiating Type Accident Secondary Type Other Initiating Type Inspection Category Safety Scope of Inspection Partial Reason No Inspection Sampling Performed? IN Expln. for No Insp. Federal Strategic Initiatives National Emphasis State Emphasis Local Emphasis Primary Emphasis Employed in Establishment 450 Walkaround? Advance Notice? Covered By Inspection 25 Interviewed? Flag for Follow-up Controlled By Employer [100 Union? Reason for Follow-up I Related Activity Activity Number Activity Type Satis?ed Establishment Name 974895 Blue Apron Inc. Related Inspections Inspection Number Establishment Name Related Inspection Type A He purge 2 TucApr "1015 12:20.25 PM ElneApmn lne. Inspecliun Nr 1055195 Addilional Codes Type In Value Deseriplion Travelers 5 IR Hear Employer Represenmives Conmelerl Narne Lust Nnrne Job Title Panieipelion lnlerviewed? Raj Alisivnn Assl. General Manage Walk Around. Credenzials. Closing Conlerence. Opening Conference Trevor Hugruves Assn General Manage Walk Around. Credenuals Closing Conference, Opening Conlerenee Samantha Bruck HR Manager Walk Around, Credcmialss Closing Conference, Opzning Conlrrenee 7 7 Employees Nnrne Toiya Adams Joh Tille Warehouse Occupation Assoeinle 1 Address Home Work Mobile -- Eml Parlicipalion Credenlials Name Jul: 1' le Walehouse oeeupnrion Assoeiore Address Home Mnhile Ennll Plrlicipution Credenlials 7 csno Sigmure 5 2 5 Dale 3 STATE OF CALIFORNIA DIV SION OF OCCUPATIONAL SAFETY AND HEALTH 1.CSEIIH L5223 Insp No 1055195 I5 Region 1 Dist. 5 WB?Blue Apron has, 7. MANAGEMENT OFFICIALS CONTACTED: DENOTES PHONE CONTACT ONLY) PRESENT DURING NAME TITLE OPENING INSPECT CLOSING Samantha Bruck HR Manager 3 Raj Atisivan Asst. Gen. Manager 5 5 Trevor Hargeaves Asst. Ge. Manager 5 8. UNION REPRESENTATIVES CONTACTED PRESENT DURING NAME TITLE LABOR UNION PHONE OPENING INSPECT CLOSING 9. Dates: 14 INSPECTION PROCEDURE Program Used I:l l:l Ki POSTER a. (Required) Program Elements Housekeeping INSURANCE Responsible Person First Aid El L0G 20. ADJUSTMENT FACTORS IN PERMITNARIANCE C?mm9m?ah?n *Good Faith ize 'story PPE Inspeguoris 30 Good 40 1-10 10 Good Investigation Procedures 30 11_25 El 5 Fair CONSENT TO emotion Procedures 15 Average El 12. EXIT CONFERENCE raining l:l 0 Poor 20 26'6? 0 PW DATE: 13 Apr 15 ecordkeeping 10 61-100 Inspection Records 0 over 100 El DISCUSS VIOLATIONS OBS. raining Recoms . *Does not apply to penalties for aCCIdent related serious or a seriousi CLOSING DATE ANTICIPTD 1e. Hazard Communication Pro ram violation with lack of an operative IIPP Program. CORRECTIVE ACTION ritten Program 21 - Maw 13. CLOSING CONFERENCE ["33"ng OWNERILLC (pls circle) a Ing EMPLOYER Storage Send Mail to: EMPLOYEES MSDS Available Business Address:3 1 5] Regatta ichmond a VIOLATIONS 17- Other Re ?imments Phone No.3109475544 FAX No. CAUOSHA Poster Posted Code of Safe Practice Main Of?ce Address: DIPInmnan FA '21 <1 ppna?'a .l . ABATEICONSULT at; ?gem phone No. 3109475644 FAX No. PENALTIES Trained First Aider Owner or Of?cer of Corporation,etc. Sddef POSTING Log 300 Posted -February Emergency Action Plan Fire Prevention Plan INFORMAL CONFERENCE APPEAL Location of Records: FOLLOWUP Respiratory Program Business License Exp. Date: Lockouthlockout VARIANCE Process Safety Mgmt' CSLB Lecense. Exp. Date. DISCRIMINATION Con?ned Space Garment Registration Exp Date: Hearing Conservation Fem or State ER Tax lm 14. Recommend Follow-up Insp. Bloodborne Pathogens Heat ?mess prevention program Farm Labor Contractor Lic Exp Date: As STATE OF CALIFORNIA DIVISION OF OCCUPATIONAL SAFETY AND HEALTH Page 2 0f 5 22. DURING INSPECTION a. b. HOME HOME PHONE PHONE C. d. HOME HOME PHONE PHONE 23. Multi-EmployerWorksite? YES NO lfyes, obtain the following information a. Employer: c. Employer: Address: Address: Activities: Activities: DContract Governing Employer?s Work at Site Contract Governing Employer?s Work at Site lAwareness of Violation El Awareness of Violation UViolation foreseeable to Employer El Violation foreseeable to Employer DSteps Taken by Employer to Protect Employees? El Steps Taken by Employer to Protect Employees? If yes, what specific steps? If yes, what speci?c steps? EIEmployer Category (Check all that apply) Employer Category (Check all that apply) Exposing [3 Creating Controlling El Correcting Exposing Creating Controlling El CorrectingE] b. Employer: d. Employer: Address: Address: Activities: Activities: EIContract Governing Employer's Work at Site Contract Governing Employer's Work at Site [IAwareness of Violation Awareness of Violation DVioIation foreseeable to Employer I:IViolation foreseeable to Employer DSteps Taken by Employer to Protect Employees? Steps Taken by Employer to Protect Employees? If yes. what specific steps? If yes, what specific steps? ElEmployer Category (Check all that apply) [Employer Category (Check all that apply) Exposing Creating Controlling Correcting Exposing Creating Controlling El Correcting [j 24. Opening and Closing Conference Summary and Additional Comments: El Comprehensive padre) Mr. Ronald Aruejo Associate Safety Engineer arrived at the site located at 3151 Regatta Blvd, Richmond, CA 94804 on 04/13/15 at approximately 10:45 A.M. Drove along Regatta Blvd. but cannot locate the site address. Called an off duty employee (previous complainant) and asked for direction. Drove to the jobsite at around 11:30 A.M. Conducted an opening conference with Ms. Samantha Bruck, HR Manager, Mr. Raj Atisivan, Asst. General Manager and Mr. Trevor Hargreaves, Assistant General Manager. Credentials were presented along with an explanation of the purpose and scope of the inspection. Ms. Samantha Bruck gave permission to Mr. Aruejo to take photographs and interview employees. Mr. Aruejo was accompanied by Ms. Samantha Bruck, Mr. Raj Atisivan and Mr. Trevor Hargreaves, during the inspection. Issued a Document Request completed for safety documentation that was not readily available. During the exit conference, potential hazards were explained to the employer along with their obligations of abatement and anticipated closing conference date. Left the facility at approximately 2:30 P.M. 25. CHECKED HISTORY: El YES [3 NO If yes. attach citation history. 26. PUBLICATIONS PROVIDED I: Guide to Poster [3 Heat Illness Prevention Other 1. 2. 3. 4. 5. STATE OF CALIFORNIA P: EDMUND G. BROWN IR, Governor Please Return To: Department of Industrial Relations Division Of Occupational Safety Health American Canyon R1 05 3419 Broadway St., Suite American Canyon, CA 94503 Tel. No. (707) 649?3700 Fax No. (707)649-3712 Attention: Ronald Arueio Additional DOCUMENT REQUEST SHEET Employer: Blue Apron Inc. Contact Name: Samantha Bruck Date: 04/14/15 Fax or Postmark 04/17/15 Received by: Samantha Bruck by. signature required As discussed during the inspection on 04/13/15, it has been determined that copies of the following documents are required for review. Please provide the inspector with the required copies by the ?Fax or Postmark by? date noted above. If the copies are not provided by that date, then it will be interpreted as an admission that the documents do not exist and possible Citations and Monetary Penalties could result. Facility layout ?oor plan, process ?ow diagram, evacuation route plan, equipment map) Rec?d Form 300 Log of Occupational Injuries and Illnesses Rec?d Years: ML 2012 2011 2014 Form 300A Summary of Occupational Injuries and Illnesses Rec?d Years: State of California Form 5020 Employer ?5 Report of Occupational Injury or Illness Rec?d for the following employee(s) El State of California Form 5021 Doctor ?3 First Report of Occupational Injury or Illness Rec?d for the following employee(s) Cl Evidence of Workers? Compensation Insurance coverage, including current Experience Modification Rating Rec?d El Injury and Illness Prevention Program, and Rec?d Inspection Records Rcc?d El Training Records Rec?d Cl Safety Committee Meeting minutes (if used) I Rec?d First Aid Kit approval physician) Rec?d Emergency Action Plan Rec?d El Heat Illness Prevention Program Rec?d Hazard Communication Program Rec?d El Material Safety Data Sheets (MSDS) for Rec?d El Respiratory Protection Program Rec?d CI Hearing Conservation Program (Noise) Rec?d El Exposure Control Program (Bloodbome Pathogens) Rec?d El Workplace Exposure Records (airborne contaminants, noise, etc.) for Rec?d El Chemical Hygiene Plan (Laboratories) Rec?d Carcinogen Registration for Rec?d El Maintenance Records for Rec?d Safety instructions/equipment operating manuals for Nissan Forklift Rec'd Written Hazardous Energy Control Program (Lockout/Tagout) training records. Rcc?d Other (describe in detail)2_ACCident Report of Ms. Toiya Adams Rec?d Federal Employer Identi?cation Number (FEIN): If you require an extension of time in order to satisjfv this request, please contact the inspector identified with your inspection at the phone numbers above. INSPECTION NO. 10551995 ID. L5223 OPT. RPT N0. 036-15 am: or CALIFORNIA ED BROWNJR Goren-or Plane Return Depanmeni or indusrnal Reiallons Division cl Occupational Safety Heailn Amerlcan canyan R1 D5 3419 Broadway St Suite American Canyon. CA 94503 Tel. No (707) 54945700 Fax No. (707) 5493712 Mention: Ronald Arue'o DOCUMENT REQUEST SHEET WW melon. Employer: Jag 559' Conlacl Nome: fl Dnte' fingng Faxor Postmark lay: Received by Warm Wm As discussed during the inspeenon nas been determincd dial copies olilre lollowing documenls are requned for review. Please [he or with file requiled Capics by m: "le oi Poslmark by" dal: "and above, [him copies are no! provided by lhal dalee Lhen it will be as an admission Lhal [he documems do no! exisl and possible Cilnlions I'll" Mnnenry Pen-mes eonld resnlr Paeilny loyoui lie lloor plan, process llow diagram, eyaenanon more plan, eqnipmenr map) Rec'd 7 Form 300 Log 12/Dccup llnesses Rcc'd Years: zuub 2012 20" fit? Form 300A Summarya l. . er Rec'd Years: :1 Son prealilornia Form 5020 Employer '5 Report aan'upattwl/Il or Illness Rec for following employeels) 1: Sure ofCalironna Form 5021 Doctor Report qucmpalmsz Iryury or Illness Rcc'd for are following employefls) Rec'd :1 Injury and Illness Preyemien Ployam, and Rcc'd El Redd B'Training Records ADAM Salery Meeting minules (If used a First Aid Kit approval (irom nee'd g/Dm'crgency Aclinn Plan TWO) 0\ Reed Heal illness Preyenrion Program Rec'd :1 Hazard Communiulinn Program Rec'd El Material Safety Dara for Rec'd Respiralory Protection Program Rcc'd a Hearing Consemtiun Program (Norse) Rec'd :1 Exposure Control Program (Bloodbarnc Pamogens) Rcc'd a Workplace Exposure Reeords (airbom: eonrammanrs, nolsc, ere for Rec'd a Chemical Hygiene Plan (Labomories) Rec'd :1 Carcinogen Regisnarion for Rec'd :1 Mainlenanee Records for Reed :1 Safely operaring manuals for Rcc'd wnnen Hazardous Energy Conlml Program (LocknuI/Taguul) Sc era ng records. Rec'd El Ree'd El Federal Employer Number (FEIM. l/yoll require an exlzmiorl of lime in order lu ratio/y (his request, please contact the inspector identified with your inspection at lhe phone numbers above N0. CSFJIH m, 0PT. N0. CILOSHA IAV c: Aruejo, Ronald@DIR From: Aruejo, Ronald@DIR Sent: Wednesday, April 15, 2015 8:52 AM To: samantha.bruck@blueaprom.com; raj@blueapron.com; trevor@blueapron.com Subject: Document requests Hello All, Good morning . Yesterday, I sent an additional document request through email. Please confirm if you have received it. I?ve talked to four (4) Warehouse Associates including Ms. Toiya Adams and I've noticed that they had certification to operate the Stand Up forklifts and Pallet trucks. However, not one of them were certi?ed to operate the sit down Nissan forklift at your backyard but were authorized to operate said forklift prior to 4/06/15. I've also indicated during my inspection on 04/13/15 that the tires were worn out and looks to be for indoor use. I?ve also pointed out a depression/uneven ground at your backyard which needs to be repaired if it will be traversed regularly by the forklift. Please do not allow the operation ofthe Nissan forklift until you have ascertained that operators are certi?ed in accordance with the requirements of T8 CCR 3668 and the uneven ground repaired. Please send me also a check list performed by employees who operated the Nissan forklift prior to April 6, 2015. The checklist should include the name of the operator who performed the equipment check. Please provide me at the earliest the course of action you have taken to correct said deficiencies. Thank you. Ronald Aruch ASE, 3419 Broadway St., American Canyon, CA 94503 Tel. No. 707-649-3700 FAX No. 707-649-3712 - 7 I. Department of Industrial Relations STATE OF CALIFORNIA