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• Pre-Inspection • Health and safety Assessment T FA#: Facilit Name: rr 77� r �D PR#: Location: S Business Type, ry v ` r'�" Date: o� i — 3 Initiall Com leted Bon during or after the inspection Fill outSubsequent Inspectionsp Re bew fa�I ty f'le anldl chem cal inventory plformation, along with the information on this form, to become fa es that should Ibe t ken pr or tol conduct ng the inspection actavity.Updatelcomplete forlm asnneeded.S'gnland date bor elow. Ph sical Hazards Chemical Hazards ❑ Ox an Deficiency: Carcino ens: Noise: Corrosives: ❑ Excavations: Flammables: ❑ Climbing: Gases: ❑ Ex losion: Metals: eav E ui ment: ❑ Oxidizers: ❑ Heat or Cold Stress: ❑ PCBs: ❑ Other: ❑ Ex losives: personal Protective E of ment Bolo ical Hazards Hard Hat ❑ CPC-T vek Cl Do s [R� Safet Vest ❑ CPC-Other: ❑ akes 9Protective Boots ❑ APR Res irator Insects Go les/Glasses ❑ SCBA Res irator ❑ Poisonous Plants Hearing Protection ❑ Other: ❑ Other: By signing below, I am declaring that I have reviewed the health and safety information for this facility prior o my will perform during the inspection, the following actions: inspection and that I have performed, and I have reviewed this form and the facility file for information on the business type of operation, compliance history, prior releases and res onse, 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 inffacility, using the Internet and ormation on the properties of the chemicals at the other resources,for chemicals I am not familiar with at this time have reviewed the facility information with my supervisor if I could not determine the most appropriate health and safety precautions needed for this facilit . 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 ap ropriate ersonal 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 z -/ 3 Revised:04-15-2013