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t • <br /> Pre-Inspection <br /> Health and Safety Assessment <br /> FacilityName: Chipotle FA#: 0020830 <br /> Location: 2310 Tienda Dr. #200 PR#: 0536821 <br /> Business Type: Fast Food <br /> Initially Completed By: Jamie DeLaRosa Date: Nov 4 2015 <br /> Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining information during or after <br /> JOCarclno <br /> ection. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this <br /> become familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary <br /> es that should be taken prior to conducting the inspection activity. Updatelcomplete form as needed.Sign and date below. <br /> al Hazardsnhazards <br /> ens: en Deficienc : <br /> rrosives: e:ammables: vations: <br /> ® Gases:CO2bin : <br /> ❑ Metals: osion: <br /> ❑ Oxidizers: Et or Cold Stress: <br /> ❑ Ex losives: r: <br /> Btolo ical Hazards Personal Protective Equipment <br /> ❑ Dos ❑ Hard Hat ❑ CPC-T vek <br /> ❑ Snakes ® Safety Vest ❑ CPC—Other: <br /> ❑ Insects ® Protective Boots ❑ APR Respirator <br /> ❑ Poisonous Plants ❑ Goggles/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 sa!qty 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 durin the ins ection. <br /> to Signature Date Staff Signature Date <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 />