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Pre- Inspection Health and Safety Assessment � 1I Facility Name : �? C7 5 w 'To �° b FAM Location : I WONcS'T , � `'� � q Q� PRM Business Type : Initially Completed By: / 40 6 �er Date: L 9 / Cf Instructions : Fill out this form as best 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 Physical Hazards ❑ Carcinogens : ; ❑ Oxygen Deficiency : ❑ Corrosives : Fie eZ ❑ Noise : ❑ Flammables : 9 ElExcavations : ElGases : WI ) GL ❑ Climbing : ❑ Metals : ❑ Explosion : ❑ Oxidizers : -Orr ❑ Heavy Equipment: ❑ PCBs : ❑ Heat or Cold Stress : ❑ Explosives : ❑ Other: Biological Hazards Personal Protective Equipment ❑ Dogs Hard Hat ❑ CPC - Tyvek ❑ 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 . ff S • gnature to Staff Signature Date 32 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