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Pre -Inspection Health and Safety Assessment Facility Name: Camanche R w Water Pumping Plant FA#: FA0018451 Location: 24235 N. Cod Rd. Clements, CA 95227 PR#: PR0527248 BusinessT e: water umping lant Initially Comdeted Bv: Aris Velc so nata, Ort 2? ?nl S Instructions: Fill out this form abest as possible before the initial inspection and complete the remaining information during or after the inspection. Subsequent In ections: Review facility file and chemical inventory information, along with the information on this form, to become familiar withpotential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken p for to conducting the inspection activity. Update/complete form as needed. Sign and date below. Chemical Hazards Physical Hazards ® Carcinogens: fuel, petrolem oils ❑ Oxygen Deficiency: N Corrosives: lead acid batte ies ❑ Noise: ® Flammables: fuel ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ Metals: ❑ Ex losion: ❑ Oxidizers: ❑ HeavyE ui ment: ❑ PCBs: N Heat or Cold Stress: ❑ I Explosives: ❑ Other: Bio lo ical Hazards Personal Protective Equipment ❑ Dos N Hard Hat ❑ CPC - T vek ❑ Snakes ® SafetyVest ❑ CPC — Other: N Insects N Protective Boots ❑ APR Respirator ❑ Poisonous Plants N Go les/Glasses ❑ SCBA Respirator ❑ 1 Other: N 1 Heging Protection ❑ Other: By signing below, I am decla ing that I have reviewed the health and safety information for this facility prior to my inspection and that I have p rformed, and will perform during the inspection, the following actions: I have reviewed this form and te facility file for information on the business type of operation, compliance history, prior releases and response, and of er health and safety related information, I have reviewed the properties nd hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluted information on the properties of the chemicals at the facility, using the internet and other resources, for chemicals 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 fac lity. I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform Imy inspection. Before beginning the inspectio, I will review the facility's health and safety information and rules with the owner/manager and wear the appropriate pers nal protective equipment. During the inspection, I will obs irve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warnin signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may aris during the inspection. r ' t' ff Signature Date Staff Signature Date San Joaquin County Envir nmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 EHD 48- 06-12-2013 Pre -Inspection Health & Safety Assessment