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0 Pre-Inspection 0 Health and Safety Assessment d3$ Facility Name '(V C iq�CAY FA#: r 2 p Location: © PRM �l J Business T Initial) Com ted B : Date: Z; Instructions Fill out this form as best as possible before the initial inspection and complete the remaining info mation during orafter the inspecti n. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this form, to b ome familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary measures t at should be taken prior to conducting the inspection activity. Update/complete form as needed. Sign and date below. Chemical i lazards Ph sica l Hazards 44- Carcinogens: ❑ oxygen Deficiency: Corro Ives: Z ❑ Noise: lam ablest ❑ I Excavations: 11Gase : ❑ Climbing: ❑ Metal . ❑ Explosion: ❑ Oxidi ll ❑ Heavy Equipment: ❑ PCBs ❑ Heat or Cold Stress: ❑ Ex to ives: ❑ Other: Biolo ical Hazards Personal Protective E ui ment ❑ 1 Dos ❑ Hard Hat ❑ CPC-T vek ❑ Snak s ❑ Safety Vest ❑ CPC-Other: ❑ Inset s ❑ Protective Boots ❑ APR Respirator ❑ Poiso ious Plants ❑ Go les/Glasses ❑ SCBA Respirator ❑ Other El Hearin Protection ❑ Other: By signin 3 below, I am declaring that I have reviewed the health and safety information for this facility prior to my inspectio i and that I have performed, and will perform during the inspection, the following actions: I have revi awed this form and the facility file for information on the business type of operation, compliance history, prior releases aid response, and other health and safety related information. I have revi awed 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 internet and other resources, for chemicals I am not familiar with at this time. I have revi wed the facility information with my supervisor if I could not determine the most appropriate health and safety precaution 3 needed for this facility. I have gair ed an awareness of the potential hazards at the facility and have determined the appropriate health and safety precaution 5 needed to perform my inspection. Before be inning the inspection, I will review the facility's health and safety information and rules with the owner/manager and wear iie appropriate ersonal 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. Staff Signature D Staff Signature Date San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 EHD 48- 06-12-)013 Pre-Inspection Health&Safety Assessment