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6 0 Pre-Inspection Health and Safety Assessment Facility Name: SJC Oak Grove Park FA#: FA0006076 Location: 5750 E. Pine St. Lodi, CA 95240 PR#: PR0514037 Business Type: Park and Recreational Department Initially Completed By: Aris Veloso Date: Aug13 2014 Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining information during or after Vmeasures on. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this come familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary hat should be taken prior to conducting the inspectionactivity.Updatelcomplete form as needed.Sign and date below. azards EaPhazards o ens: etroleumructsen Deficiencsives: s ent lead acid batteries : ables: vations: ❑ Gases: in : ❑ Metals: ❑ Ex losion: ❑ Oxidizers: ❑ Heavv E ui ment: ❑ PCBs: ® Heat or Cold Stress: hot weather ❑ Explosives: ❑ Other: Biolo ical Hazards Personal Protective E ui ment ❑ Dos ® Hard Hat ❑ 1 CPC-T vek ❑ Snakes ® 1 Safetv Vest ❑ CPC—Other: 19 Insects ® Protective Boots ❑ APR Res irator ❑ Poisonous Plants ® Go les/Glasses C3SCBA Res irator ❑ Other: 10 1 Hearing Protection ❑ Other: By signing below, I am declaring that I have reviewed the health and safety information for this facility prior to my inspection and that I have performed, and will perform during the inspection, the following actions: I have reviewed this form and the facility file for information on the business type of operation, compliance history, prior releases and response,and other health and safety related information. I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluated information on the properties of the chemicals at the facility, using the intemet and other resources, for chemicals I am not familiar with at this time. I have reviewed the facility information with my supervisor if I could not determine the most appropriate health and safety precautions needed for this facility. I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform my ins ection. Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager and wear the appropriate personal protective equipment. During the inspection, I will observe the labeling and condition of hazardous materials containers and conveyances,the posting of placards and warning signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may arise during the ins ection. Stallf Pignature Date Staff Signature Date 11'�1 San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue;Stockton,CA 95205;209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment