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COMPLIANCE INFO PRE 2019
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PR0527831
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COMPLIANCE INFO PRE 2019
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Last modified
2/27/2019 4:31:21 PM
Creation date
2/27/2019 2:22:40 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2200 - Hazardous Waste Program
File Section
COMPLIANCE INFO
FileName_PostFix
PRE 2019
RECORD_ID
PR0527831
PE
2220
FACILITY_ID
FA0003626
FACILITY_NAME
OAK PARK GAS & CONVENIENCE STORE
STREET_NUMBER
3212
Direction
N
STREET_NAME
CALIFORNIA
STREET_TYPE
ST
City
STOCKTON
Zip
95204
APN
12532001
CURRENT_STATUS
01
SITE_LOCATION
3212 N CALIFORNIA ST
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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EHD - Public
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Pre-Inspection <br /> Health and Safety Assessment <br /> Facility Name: J,! FA#:6 /� <br /> Location: �j�l� CG� � G�, PR#: <br /> Business T e: 7161C <br /> Initially Completed By: �IL Date: p$ <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 Physical Hazards <br /> Carcinogens ❑ Oxygen Deficiency: <br /> ❑ Corrosives:. ❑ Noise: <br /> Flammables: L,,cjj ❑ Excavations: <br /> Gases: ❑ Climbing: <br /> ❑ Metals: ❑ Ex losion: <br /> ❑ Oxidizers: ❑ Heavy Equipment: <br /> ❑ PCBs: ❑ Heat or Cold Stress: <br /> ❑ I Explosives: ❑ Other: <br /> Bio lo ical Hazards Personal Protective E ui ment <br /> ❑ Dos ❑ Hard Hat ❑ CPC-T vek <br /> ❑ Snakes ❑ Safety Vest ❑ CPC—Other: <br /> ❑ Insects Protective Boots ❑ APR Respirator <br /> ❑ Poisonous Plants Go les/Glasses ❑ SCBA Respirator <br /> ❑ 1 Other: ❑ Hearing 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 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 during the inspection. <br /> Staff Signature Date Staff Signature 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 />
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