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Pre-Inspection Health and Safety Assessment Facili Name: ch FA#: 000 3r7;�?_o Location 670e W Z))- M � � 11- alv , PR#: 6231ac3 -7 Business T e: 17 Initially Completed BY: ✓g_1-e;(_ Date: Instructions: Fill out this form as t 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 s'cal Hazards Carcino ens: S ❑ Ox en Deficiency: Corrosives: ❑ Noise: Flammables: ►'b Q*�Lo_ CLtJ0 ❑ Excavations: Gases: 1} 02K?2 02 ❑ Climbing: ❑ Metals: i ❑ Ex losion: ❑ Oxidizers: Heav E ui menta V ❑ PCBs: ❑ Heat or Cold Stress: ❑ Ex losives: ❑ Other: Biolo ical Hazards I Personal Protective E ui ment ❑ Dos ❑ Hard Nat ❑ CPC-T vek ❑ Snakes Safet Vest ❑ CPC—Other: Insects / Protective Boots ❑ APR Respirator ❑ Poisonous lants 01 Goggles/Glasses ❑ SCBA Res irator ❑ Other: ❑ 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 safetl related information. I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have seEneeded and evaluated information on the properties of the chemicals at the facility, using the internet and other resochemicals I am not familiar with at this time. I have revfacility information with my supervisor if I could not determine the most appropriate health and safety recautiofor this facilit . I have gained anawareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform m ins ection. Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager and wear thea ropriate 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 during the inspection. Sta t ature Dat Staff Signature Date L'2( /3 to 12z 1 /S San Joaquin County Environmental Health Dep artment; 1868 E. Hazelton Avenue;Stockton,CA 95205;209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment