Laserfiche WebLink
Pre -Inspection <br />Health and ! Safety Assessment �% <br />aA)rAXJ 1 10 v�0%� FA#: `0 <br />Location: n -n 14Ll.V e, L-- . PR#: S I�— Z9 <br />Business <br />Initially Completed BY: k-) Date: I a// IV /7e) / l <br />Instructions: Fill out this form as best as possible before the initi&4itfspection and complete the remaining information during or after <br />the inspection. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this <br />form, to become familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary <br />measures that should be taken prior to conducting the inspection activity. Update/complete form as needed. Sign and date below. <br />Chemical Hazards Physical Hazards <br />❑ Carcinogens: ❑ Oxygen Deficiency: <br />❑ Corrosives: ❑ Noise: <br />Flammables: ❑ Excavations: <br />❑ Gases: ❑ Climbing: <br />❑ Metals: ❑ Explosion: <br />❑ Oxidizers: ❑ Heavy Equipment: <br />❑ PCBs: ❑ Heat or Cold Stress: <br />❑ 1 Explosives: 01 Other: <br />Biolo ical Hazards Personal Protective E ui ment <br />❑ Dos ❑ 1 Hard Hat ❑ 1 CPC - Tyvek <br />❑ Snakes ❑ Safety Vest ❑ CPC — Other: <br />❑ Insects ❑ Protective Boots ❑ APR Respirator <br />❑ Poisonous Plants ❑ Go les/Glasses ElSCBA 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 safety 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 during the ins ection. <br />taff Signatyre, <br />Date <br />Staff Signature <br />Date <br />D / <br />San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 <br />EHO48- 06-12-2013 Pre -Inspection Health & Safety Assessment <br />