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Pre-Inspection Health and Safety Assessment Facili Na e: TRULGACM FAM. �:T Location: PR#: S �� Business Type: Initially Cor pleted By: Date: Instructio s: Fill out this form as best as posibile befo initial inspection and complete the remaining information during or after the insp tion. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this form, toecome familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary measure that should be taken prior to conducting the inspection activity. Update/complete form as needed.Sign and date below. Chemica Hazards Ph scal Hazards Carcinogens: ❑ Oxygen Deficiency: ❑ Corrosives: ❑ Noise: Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: E03 Met Is: ❑ Explosion: ❑ Oxidizers: Heavy Equipment: ❑ PCBs: Heat or Cold Stress: ❑ Explosives: ❑ Other: Biological Hazards Personal Protective E ui ment ❑ Dos ❑ Hard Hat ❑ CPC-T vek Snakes X1 Safety Vest ❑ CPC—Other: Insects Xj Protective Boots ❑ APR Respirator ❑ Poisonous Plants 01 Goggles/Glasses SCBA Respirator ❑ Other: 01 Hearing Protection Other: By signing below, I am declaring that I have reviewed the health and safety information or 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. I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have si arched out and evaluated information on the properties of the chemicals at the facility, using the internet and other rei ources,for chemicals I am not familiar with at this time. I haver viewed the facility information with my supervisor if I could not determine the most appropriate health and safety recauti ns needed for this facility. I have g iined 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 ownerlmanager 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 ulonditions that may arise during the inspection. Staff Signature Date Staff Signature Date I 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