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0 0 Pre-Inspection T Health and Safety Assessment y� Facility Name S �(1QL� I /T_ Il P 7l� FA#: (/tl) N Location hQ�� I - G{(V1 o� PR# WWI 9 Tr Business Type? Initially Completed By: J Date: 10 Instructions: Fill out this form as bes as possible before the initial inspection and complete the remaining information during or after the inspection. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this form, to become familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken prior to conducting the inspection activity. Updatelcomplete form as needed.Sign and date below. PSnakes l Hazards Ph sical Hazards cino ens: an Deficiency: rosives: ❑ Noise: mables: ❑ Excavations: es: ❑ Climbin tals: ❑ Ex losion: dizers: ❑ Heav E ui menta Bs: ❑ Heat or Cold Stress: losives: ❑ Other: al Hazards Personal Protective E ui ment s ❑ Hard Hat ❑ CPC-T vek akes ❑ SafetyVest ❑ CPC—Other: ects Protective Boots ❑ APR Respirator ❑ Poisonous PlantsI ❑ I Goggles/Glasses ❑ 1 SCBA Respirator ❑ 1 Other: 101 Hearing Protection ❑ I 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 P .searched out and evaluated information on the properties of the chemicals at the facility, using the intemet and resources,for chemicals I am not familiar with at this time.reviewed the facility information with my supervisor if I could not determine themost appropriate health and safety utions needed for this facilit . gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety utions needed to erform m ins ection. e beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager ear the a ro riate ersonal rotective a ui ment. g the inspection, I will observe the labeling and condition of hazardous materials containers and conveyances, the ng of placards and warning signage, and the actions of the facility employees and guests to identify any potential fe conditions that ma arise duringthe inspection. Staff Signature Date Staff Signature Date 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