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Pre-Inspection Health and Safety Assessment FacilityName: FA#: v� Yj✓ Location: PR#: Business Type: Initially Completed By: Date: ANY Instructions: Fill out t is form as est as possibl efore 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 potential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken pri r to conducting the inspection activity. Updatelcomplete form as needed.Sign and date below. Chemical Hazards Physical Hazards De Carcinogens: ❑ 1 Oxygen Deficiency: Corrosives: ❑ Noise: Flammables: ❑ Excavations: Gases: ❑ Climbing: Metals: ❑ Explosion: ❑ Oxidizers: Heavy Equipment: ❑ PCBs: Heat or Cold Stress: ❑ I Explosives: ❑ Other: Bio lo ical Hazards Personal Protective Equipment Dos ❑ Hard Hat ❑ CPC-T vek Snakes Safety Vest ❑ CPC—Other: 7K2 Insects Protective Boots ❑ APR Respirator Poisonous Plants Goggles/Glasses ❑ SCBA Respirator ❑ Other: ❑ Hearing Protection ❑ Other: By signing below, I am declang 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 t e facility 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 propertiesnd hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluaed 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 inforation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this facil t . I have gained an awareness of he 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 perso al protective equipment. During the inspection, I will obSE rve 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 ariSE during the inspection. Staff Signature D to Staff Signature Date San Joaquin County Enviroi imental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205;209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment