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Pre-Inspection Health and Safety Assessment Facility Name: () 'k;&A C, FA#: I Location: l 1� PR#: j 0 Business T pe: 5''c'GC Initially Completed By: n U Date: Instructions: Fill out this form as t est as possible befor 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 pri r 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: ❑ Heav Equi ment: ❑ PCBs: ❑ Heat or Cold Stress: ❑ 1 Explosives: ❑ I Other: Bio lo ical Hazards Personal Protective Equipment ❑ Dos ❑ Hard Hat 01 CPC-T vek ❑ Snakes ❑ SafetyVest ❑ I CPC—Other: ❑ Insects ❑ Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Goggle /Glasses ❑ SCBA Respirator ❑ I Other: ❑ I Hearing 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 performed, and will perform during the inspection, the following actions: have reviewed this form and he 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 propertier and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evall.ated information on the properties of the chemicals at the facility, using the internet and other resources, for chemicalq I am not familiar with at this time. I have reviewed the facility in rmation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this I have gained an awareness f the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform my 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 per onal protective equipment. During the inspection, I will observe 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 a ise during the inspection. Staff Signature Date Staff Signature Date c 2tie.; If�--7 -tom San Joaquin County En ironmental Health Department; 1868 E. Hazelton Avenue; Stockton,CA 95205;209.468.3420 EHD 48-06-12-2013 Pre-Inspection Health&Safety Assessment