Laserfiche WebLink
0 <br />Pre -Inspection <br />/Health and Safety Assessment <br />Facility Name: _ { � e -j 6vg� FA#: pob ��q S <br />Location: W kr _- _ IPAIVI c"I_ PR#: 4 Z 3 Sl <br />Business Tvl?e: 111 Ii.I LrA <br />nitially Completed By: �;kVV vil) Date: 1`/2W/15 <br />Instructions: Fill out this form as best as possible before the initial inspection 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 <br />Ph sical Hazards <br />X1 <br />Carcinogens: <br />❑ <br />Ox an Deficienc ; <br />❑ <br />Corrosives: <br />❑ <br />Noise: <br />Flammables: <br />❑ <br />Excavations: <br />❑ <br />Gases: <br />EJ <br />Climbin . <br />F-1 <br />Metals: <br />❑ <br />Ex losion: <br />❑ <br />Oxidizers: <br />Heavy E ui ment: ✓G(%td,,j <br />❑ <br />PCBs: <br />❑ <br />Heat or Cold Stress: <br />❑ <br />Explosives: <br />❑ <br />Other: <br />81010 'cal Hazards <br />Personal Protective Equipment <br />❑ <br />Dos <br />Hard Hat <br />❑ <br />CPC - T vek <br />❑ <br />Snakes <br />X <br />Safety Vest <br />ElCPC <br />- Other: <br />❑ <br />Insects <br />Protective Boots <br />❑ <br />APR Res iratar <br />❑ <br />Poisonous Plants <br />❑ <br />Goggles/Glasses <br />❑ <br />SCBA Res irate <br />❑ <br />Other: <br />❑ I <br />Hearin Protection <br />❑ <br />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 />1 have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the <br />fnriliiv <br />I have searched out and evaluated information on the properties of the chemicals at the facility, using the interne nand <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 facilit . <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 durinq the inspection, <br />Staff Signature <br />Date <br />(r <br />Staff Signature <br />Date <br />San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 <br />EHD 48 06-12-2013 Pre -Inspection Health & Safety Assessment <br />