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• i <br /> Pre-Inspection <br /> Health and Safety Assessment <br /> Facility Name: ChipOtle FA#: FA0018861 <br /> Location: 1442 Hulsey PR#: PR0540064 <br /> Business Type: Fast Food <br /> Initially Completed By: Pete Lombardi Date: Jun 15 2015 <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: Coe ❑ Climbing: <br /> ❑ Metals: ❑ Explosion: <br /> ❑ Oxidizers: ❑ Heavy Equipment: <br /> ❑ PCBs: ❑ Heat or Cold Stress: <br /> ❑ Ex losives: ❑Tother: <br /> Biolo ical Hazards Personal Protective E ui ment <br /> ❑ Dos ❑ Hard Hat ❑ CPC-Tyvek <br /> ❑ Snakes ❑ Safety Vest ❑ CPC—Other: <br /> ❑ Insects S Protective Boots ❑ APR Respirator <br /> ❑ Poisonous Plants ® Go les/Glasses ❑ SCBA Respirator <br /> ❑ Other: ❑ 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 /> 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 inspection. <br /> Staff Signa ure Date Staff Signature Date <br /> - 6/ <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 />