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Pre-Inspection Health and Safety Assessment Facility Name: 1 S FA#: Location: �ja D PRS#: 7 Business Type: k � w U Initially Completed B : Date: Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining information during or after the inspection. Subsequent Ins ections: Review facility file and chemical inventory information, along with the information on this form, to become familiar with p tential 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. Updatelcomplete form as needed.Sign and date below. Chemical Hazards Physical Hazards TSj Carcino ens: ❑ Oxygen Deficiency: ❑ Corrosives:. U rEl Noise: 'N Flammables: Excavations: ❑ Gases: Climbing: El Metals: Explosion: ❑ Oxidizers: HeavyEqui ment: ❑ PCBs: ❑ Heat or Cold Stress: ❑ Explosives: ❑ Other: Biological Hazards Personal Protective Equipment ❑ Dos ❑ 1 Hard Hat ❑ CPC-T vek ❑ Snakes ❑ Safety Vest ❑ CPC—Other: ❑ Insects Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Go les/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 pe ormed, 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 evalua ed 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 info ation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this faci ity. I have gained an awareness of he potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform Oy 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 erso al protective equipment. During the inspection, I will obsrve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warning signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may aris during the inspection. tall Signature Date Staff Signature Date San Joaquin County Enviroi mental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205;209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment