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Pre- Inspection Health and Safety Assessment Facility Name : % u G� Lrt p,� 2s/ ✓� � � FA#: FA00 Location : / L� i Z )6V PR#: PRO Business Type : A 4q go Z4., , •491±2 /fi e✓ ✓� 1 Initially Completed By: Robert Lopez Date : /3 / Instructions : Fill out this form as best as possible before the initial inspection and complete the remaining Inform Ion 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 Ph sical Hazards ❑ Carcinogens : _ ❑ Oxygen Deficiency: ❑ Corrosives : X60 ❑ Noise : p Flammables : Q j; 4 z ❑ Excavations : Gases : A ,` ❑ Climbing : ❑ Metals : a ❑ Explosion : ❑ Oxidizers : r c ❑ Heavy Equipment: ❑ PCBs : d ❑ Heat Stress : ❑ Explosives : o ' ❑ Cold Stress : Other: ❑ Other: Biolo ical Hazards Personal Protective Equipment ❑ Dos X Hard Hat ❑ CPC - T vek ❑ Snakes X Safety Vest ❑ CPC — Other: ❑ Insects X Protective Boots ❑ APR Respirator ❑ Poisonous Plants X Goggles/Glasses ❑ SCBA Respirator ❑ Other: X 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 . Staff Signature Date Staff Signature Date Robert Lopez VM 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