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Pre -Inspection Health and Safety Assessment Facility Name: 1ACLA AD\, FAP &11 8 3 8 Location: :) CA PR#: oe - Business Type: 64 lnifiallv('.mmnlPfarl Rv 1 -2 n noil Date: (,a Instructions: Fill out this form as best as possible before the nitial 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 with Dotential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken prior to conducting the inspection activity. Updatelcomplete form as needed. Sign and date below. Chemical Hazards Physical Hazards FP Carcinogens: ❑ Oxygen Deficient : ❑ Corrosives: ❑ Noise: ❑ Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ Metals: ❑_ Explosion: ❑ Oxidizers: ❑ Heavy Equipment: ❑ PCBs: ❑ Heat or Cold Stress: ❑ Explosives: • ❑ Other: Biological Hazards Personal Protective Equipment ❑ Dos Hard Hat • ❑ CPC - T vek ❑ Snakes Safety Vest ❑ CPC — Other: ❑ Insects QF Protective Boots ❑ APR Respirator ❑ Poisonous Plants Goggles/Glasses ❑ SCBA Respirator El Other: ❑ Hearin Protection ❑ Other: By signing below, I am dec aring that I have reviewed the health and safety information for this facility prior to my inspection and that I have 1 ierformed, and will perform during the inspection, the following actions: I have reviewed this form an the facility file for information on the business type of operation, compliance history, prior releases and response, and i ither health and safety related information. have reviewed the properflE s and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and eva uated 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 f 3cility. I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perfo m my inspection. Before beginning the inspec on, I will review the facility's health and safety information and rules with the owner/manager and wear the appropriate pe sonal protective equipment. During the inspection, I will c bserve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warr ing signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may rise during the inspection. Staff Signature Date Staff Signature Date San Joaquin County Evironmental Health Uepartment; 1bbd E. Hazelton Avenue; StocKton, t;A ySZUb; ZUa.4bt1.j4Zu EHD 48- 06-12-2013 Pre -Inspection Health & Safety Assessment