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Pre- Inspection Health and Safety Assessment Facility Name : rr6 c, e.�, scs cofv C, -L / FA#: Location : t � b /�/ c: !Z �Gt . , -S�o � e� pL� � PR#: Business Type : lwej f CCA "- i 4" LAe JdOGjw Initially Completed By: We ker Cle e� Date : , � 9 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 : ❑ Noise : ❑ Flammables : ❑ Excavations : Gases : 42-�6/\ ❑ Climbing : ❑ Metals : ❑ Explosion : ❑ Oxidizers : ❑ Heavy Equipment : ❑ PCBs : ❑ Heat or Cold Stress : ❑ Explosives : ❑ 1 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 I nspection 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 gate,, Staff Signature Date ?LIP ell T 771 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