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c Pre -Inspection / Health and Safety Assessment Name: 1 A r l o a C/ 7 i#C �L /lam L� FA#: Location: ajE7 PR#: D 220 0 Business T e:ML 2 Initially Completed Bv: ((.VN C� <<, O ./'7,l � Date: f 1 Instructions: Fill out this for s est as possible before the initial inspection and complete the remaining information during or after the inspection. Subsequent Insp 2ctions: Review facility file and chemical inventory information, along with the information on this form, to become familiar with po ential 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 I Physical Hazards Carcinogens: / S-tx �� t- L� c .V ❑ Oxygen Deficiency: Corrosives: Ala Q14 e a. C Noise: Flam mables: & Excavations: Gases: P.I7 ❑ Climbing: Metals: '` r,&0 ❑ Explosion: lF Oxidizers: M4,0XXI Heavy Equipment: TM ❑ PCBs: ❑ Heat or Cold Stress: ❑ Ex losives: ❑ Other: Biological Hazards Personal Protective E ui ment ❑ Dos 'X Hard Hat ❑ 1 CPC - T vek ❑ Snakes SafetyVest ❑ CPC - Other: Insects � Protective Boots ❑ APR Respirator ❑ Poisonous Plants Go les/Glasses ❑ SCBA Respirator ❑ Other: Hearin 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 pe ormed, and will perform during the inspection, the following actions: I have reviewed this form and thfacility file for information on the business type of operation, compliance history, prior releases and response, and oth r health and safety related information. I have reviewed the properties a id hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluat d information on the properties of the chemicals at the facility, using the intemet and other resources, for chemicals I am not familiar with at this time. I have reviewed the facility info# ation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this facili . I have gained an awareness of t e potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform 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 person I protective equipment. During the inspection, I will obse ve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warning 3ignage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may arise during the ins ection. Staff Wgture Date Staff Signature Date San Joaquin County Environ ental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 EHD 48- 06-12-2013 Pre -Inspection Health & Safety Assessment