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Pre-inspection <br /> Health and Safety Assessment <br /> Facility Name!-,) �A FA#.�A 1P ID(a3b <br /> Location: -7;; () 6' PR#: W,05-kLi3ci-z., <br /> Business Type: <br /> Initially Completed By: 5; L Date: <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 Ph sical Hazards <br /> Corrosives: <br /> Carcinogens: 0 Ox en Deficlenc <br /> • Corrosives: 0 Noise: <br /> C <br /> Ca <br /> 0 r <br /> rc <br /> r <br /> in <br /> 0, <br /> T <br /> • Flammables: 0 Excavations: <br /> El Gases: 0 Climbing: <br /> 0 Metals: g_ Explosion: <br /> 0 Oxidizers: 0 Heavy Equipment: <br /> • PCBs: 0 Heat or Cold Stress: <br /> • Explosives: 0 Other: <br /> B 10 ic I <br /> ioa Hazards Personal Protective Eguipment <br /> r_1 2V _0 <br /> 0 1 n� X I Hard Hat ❑ CPC-Tyvek <br /> El Snakes [9 Safety Vest 0 CPC—Other: <br /> El Insects � Protective Boots 0 APR Respirator <br /> El Poisonous Plants _ffl GoggleslGlasses 0 SCBA Respirator <br /> 0 Other: 0 Hearin o Protection 0 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 ins ection. <br /> Staff Signature Date Staff Signature Date <br /> Ll�,AIIA�IP _3 <br /> San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue;Stockton,CA 95205;209.468,3420 <br /> EHD48- 06-12-2013 Pre-finspecdon Health&Safety Assessment <br />