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Pre- Inspection Health and Safety Assessment Facility Name : C / ' L )0 t' 4 S �c Q d l� ; rr r� va 4 &." c -e FAM Location : C !7 a i , / 7'�O ,I, Cf 5j ZCS �� PRM Business Type : [_� ACL l cv�o c/ .0� 4�1 coeot ti Initially Completed By: 2 Date: Instructions : Fill out this form as rest as possible before the initial inspection and complete the remainir4 inforafation 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 Physical Hazards ❑ Carcinogens : 01 Oxygen Deficiency : ❑ Corrosives : CoA- ` �, ❑ Noise : ❑ Flammables : ❑ Excavations : ❑ Gases : ❑ Climbing : Metals : ❑ Explosion : ❑ Oxidizers : Heavy Equipment : ❑ PCBs : G '� ❑ Heat or Cold Stress : ❑ Explosives : ❑ Other: Biological Hazards Personal Protective Equipment ❑ Dogs Hard Hat ❑ CPC - T vek ❑ Snakes Safety Vest ❑ CPC — Other: ❑ Insects Protective Boots ❑ APR Respirator ❑ Poisonous Plants Goggles/Glasses ❑ SCBA Respirator ❑ Other: Hearing 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 . I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluated information on the properties of the chemicals at the facility, using the internet and 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 facility. 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 during the inspection . St ff Signature at 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