COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

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Pre-Inspection Health and Safety Assessment Facility Name: 1. FA#: 11 Location: �n PR* qW Business Type: Initially Completed By: Date: Instructions: Fill out this formas best as possible before the Wal al 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 withPor tential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken to conducting the inspection activity.Updatelcomplete form as needed.Sign and date below. Chemical Hazards Physical Hazards Carcinogens: ❑ Oxygen Deficiency: Corrosives: ❑ Noise: ❑ Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ Metals: ❑ Explosion: ❑ Oxidizers: ❑ Heavy Equipment: ❑ PCBs: - ❑ Heat or Cold Stress: ❑ I Explosives: ❑ 1 Other: Biological Hazards Personal Protective Equipment 11 Dogs Hard Hat . ❑ CPC-T vek ❑ Snakes Safety Vest ❑ CPC—Other: ❑ Insects RV Protective Boots ❑ APR Respirator 11Poisonous Plants Gogg les/Glasses ❑ SCBA Respirator ❑ I Other: 1 ❑ Hearing Protection ❑ Other: By signing below, I am dedring 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 andthe facility file for information on the business type of operation,compliance history,prior releases and response, and o her health and safety related information. I have reviewed the propertieand hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evalated information on the properties of the chemicals at the facility, using the internet and other resources,for chemical I am not familiar with at this time. I have reviewed the facility inrmation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this f ility. I have gained an awarenessf the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perfor my inspection. Before beginning the inspecti n, I will reviewthe facility's health and safety information and rules with the owner/manager and wear the appropriate pe:nal protective equipment. During the inspection, I will ot serve the labeling and condition of hazardous materials containers and conveyances,the posting of placards and warni ig signage,and the actions of the facility employees and guests to identify any potential unsafe conditions that may ar se during the inspection. Staff Signaturel Date Staff Signature Date San Joaquin County Env ronmental Health Department; 1868 E. Hazelton Avenue; Stockton,CA 95205;209.468.3420 EHo 48-06-12-2013 Pre-Inspection Health&Safety Assessment