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Pre-Inspection <br /> 1� Health and Safety Assessment <br /> Facility Name• (\ \ 1 (h Q �O(A FA#. OA7 <br /> Local on 9 S �� nri A A9 l/�Q_ f-- t o 0 , r PR# ( r _- o <br /> Business Type: P Jp �[.�ltusJ -- <br /> Initially Completed By: 7 Date: <br /> Instructions: Fill out this form as best as possible before ther1nitial 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 betaken pdor to conducting the inspection activity.Update/complete form as needed.Sign and date below. <br /> Chemical Hazards Physical Hazards <br /> Carcino ens: ❑ 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: ❑ Other: <br /> Blolo ical Hazards Personal Protective Equipment <br /> ❑ Dos 91 Hard Hat - 1 ❑ CPC-T ek <br /> ❑ Snakes lin Safety Vest ❑ CPC—Other: <br /> ❑ Insects ICJ Protective Boots ❑ APR Respirator <br /> ❑ Poisonous Plants Go leslGlasses ❑ SCBA Res irator <br /> ❑ Other. 11 Head <br /> 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 ownerimanager <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 /> Staff Signature Date Staff Signature Date <br /> 7� <br /> San Joaquin County Environmental Health Department;1868 E.Hazelton Avenue;Stockton,CA 95205;209.468.3420 <br /> EHO 48-M12-2013 Pre-Inspection Health&Safety Assessment <br />