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• • Pre-Inspection Health and Safety Assessment FA#: Facility Name: Location i Business T e ✓ Date: lni6all Com feted B and c, Instructions: Fill out u bsecuent InspectionsP Review facility f le ale efore the tnd chemicial a l Inventory information along wlith the information on this the inspection. 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. ph form as needed.Sign and date below. h sical emical Hazards Ox an Deficienc : Carcino ens: S Noise: ❑ Corrosives: Excavations: Flammables: ❑ Climbin i- Gases: Asg 42 ❑ Ex losion: ❑ Metals: Heavy Equipment' 9: Oxidizers: ❑ Heat or Cold Stress: ❑ PCBs: ❑ I Other: ❑ Ex losives: Personal Protective E ui ment Biolo icalHazards ❑ Hard Hat ❑ CPC-T vek ❑ Do s Safe Vest ❑ CPC—Other: ❑ Snakes Protective Boots ❑ APR Res irator ❑ Insects ❑ Go les/Glasses ❑ SCBA Res irator ❑ Poisonous Plants ❑ Hearin Protection ❑ Other: ❑ 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 busif mpliance history, prior ness type ooperation,co releases and res onse,.and other health and safe related information. I have reviewed the properties and hazards associated with the chemicals in the chtory submitted by the emical inven facili . I have searched out and evaluated information on the properties of the chemicals at the facility, using the Internet an 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 recautions needed for this facilit . I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety recautions needed to perforM Mly inspection. Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager and wear thea to date 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 action.te Staff Signature Date Staff ature - 2 San Joaquin County Environmental Health Department;1868 E.Hazelton Avenue;Stockton,CA 95205; 09 6lth&.Ory�sessment EHD 48- 06-12-2013