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0 Pre -Inspection /Health and Safety Assessment Facility Name: _ { � e -j 6vg� FA#: pob ��q S Location: W kr _- _ IPAIVI c"I_ PR#: 4 Z 3 Sl Business Tvl?e: 111 Ii.I LrA nitially Completed By: �;kVV vil) Date: 1`/2W/15 Instructions: Fill out this form as best 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, Update/complete form as needed. Sign and date below. Chemical Hazards Ph sical Hazards X1 Carcinogens: ❑ Ox an Deficienc ; ❑ Corrosives: ❑ Noise: Flammables: ❑ Excavations: ❑ Gases: EJ Climbin . F-1 Metals: ❑ Ex losion: ❑ Oxidizers: Heavy E ui ment: ✓G(%td,,j ❑ PCBs: ❑ Heat or Cold Stress: ❑ Explosives: ❑ Other: 81010 'cal Hazards Personal Protective Equipment ❑ Dos Hard Hat ❑ CPC - T vek ❑ Snakes X Safety Vest ElCPC - Other: ❑ Insects Protective Boots ❑ APR Res iratar ❑ Poisonous Plants ❑ Goggles/Glasses ❑ SCBA Res irate ❑ Other: ❑ I Hearin Protection ❑ 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 1 have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the fnriliiv I have searched out and evaluated information on the properties of the chemicals at the facility, using the interne nand 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 precautions needed for this facilit . I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform -My inspection. Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager and wear the appropriate personal 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 durinq the inspection, Staff Signature Date (r 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