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Pre -inspection <br />Health and Safety Assessment <br />Facili Name: J FA#: FA00 <br />Location: ! % IP 1 (1111,1111 t, /n c o C),S—Z 0 /0 PR#: PRO <br />M_ <br />Initially Completed By: Robert Lopez Date: L / 2/ , .P <br />Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining information during or after <br />the inspection. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this <br />form, to become familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary <br />measures that should be taken prior to conducting the inspection activity. Update/complete form as needed. Sign and date below. <br />Chemical Hazards Physical Hazards <br />❑ Carcinogens: ❑ Oxygen Deficiency: <br />❑ Corrosives: ❑ Noise: <br />❑ Flammables: ❑ Excavations: <br />❑ Gases: eT ❑ Climbing: <br />❑ Metals: ❑ Explosion: <br />❑ Oxidizers: ❑ Heavy Equipment: <br />❑ PCBs: ❑ 1 Heat Stress: <br />❑ Explosives: ❑ Cold Stress: <br />❑ Other: ❑ Other: <br />Bio lo ical Hazards Personal Protective E ui ment <br />❑ Dogs X Hard Hat ❑ CPC - Tyvek <br />❑ Snakes X Safety Vest ❑ CPC —Other: <br />❑ Insects X Protective Boots ❑ APR Respirator <br />❑ Poisonous Plants X Goggles/Glasses ❑ SCBA Respirator <br />❑ Other: X Hearing Protection ❑ Other: <br />By signing below, I am declaring that I have reviewed the health and safety information for this facility prior to my <br />inspection and that I have performed, and will perform during the inspection, the following actions: <br />I have reviewed this form and the facility file for information on the business type of operation, compliance history, prior <br />releases and response, and other health and safety related information. <br />I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the <br />facility. <br />I have searched out and evaluated information on the properties of the chemicals at the facility, using the internet and <br />other resources, for chemicals I am not familiar with at this time. <br />I have reviewed the facility information with my supervisor if I could not determine the most appropriate health and safety <br />precautions needed for this facility. <br />I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety <br />precautions needed to perform my inspection. <br />Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager <br />and wear the appropriate personal protective equipment. <br />During the inspection, I will observe the labeling and condition of hazardous materials containers and conveyances, the <br />posting of placards and warning signage, and the actions of the facility employees and guests to identify any potential <br />unsafe conditions that may arise during the ins ection. <br />Staff Signature <br />Date <br />Staff Signature <br />Date <br />Robert Lopez <br />2 <br />San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 <br />EHD 48- 06-12-2013 Pre -Inspection Health & Safety Assessment <br />