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Pre-Inspection \ Health and Safety Assessment Facility Name: FA#: Location: ! 0 � PR#: Business Type: r? G1 Y Initially Completed By: Date: (� Instructions: Fill out this form st as possib efore the initial inspection and complete the remaining infor atlon 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 potential 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 Physical Hazards Carcinogens: ❑ Oxygen Deficiency: ❑ Corrosives: ❑ Noise: Flammables: ` ❑ Excavations: Gases: ❑ Climbin : -Eik-I Metals: A, S ❑ Explosion: ❑ Oxidizers: ❑ HeavyE ui ment: ❑ PCBs: ❑ Heat or Cold Stress: ❑ Explosives: ❑ Other: Bio lo ical Hazards Personal Protective Equipment ❑ Dos ❑ Hard Hat ❑ CPC-T vek ❑ Snakes ❑ Safety Vest ❑ CPC-Other: ❑ Insects ❑ Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Goggles/Glasses ❑ SCBA Respirator ❑ 1 Other: ❑ Hearing 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 andt e 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 evalu ted 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 info mation 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 ofhe potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform y 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) al protective equipment. During the inspection, I will obs rve 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. Sta ignature Date Staff Signature Date San Joaquin County Enviro mental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment