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Pre-Inspection Health and Safety Assessment J FA# 3 Facility Name: S 1- J Location: c7 CLc l7 -4- n PR#: Business Type: Initially Completed By: Date: Instructions: Fill out this form as est as possible before the initla ' spection 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 pr or to conducting the inspection activity.Updatefcomplete form as needed.Sign and date below. Chemical Hazards Physical Hazards Ell Carcinogens: ❑ Oxygen Deficiency: ❑ Corrosives: ❑ Noise: ❑ Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ I Metals: ❑ Explosion: ❑ Oxidizers: ❑ Heavy Equipment: ❑ PCBs: - ❑ Heat or Cold Stress: ❑ Explosives: • ❑ 1 Other: Biological Hazards Personal Protective Equipment ❑ Dogs [if I Hard Hat ' ❑ CPC-Tyvek ❑ Snakes CA Safety Vest ❑ CPC—Other: ❑ Insects 171 Protective Boots ❑ APR Respirator ❑ Poisonous Plants U Goggles/Glasses ❑ SCBA Respirator ❑ 1 Other: ❑ 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 1 have performed, and will perform during the inspection, the following actions: I have reviewed this form and the 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 propertie and hazards associated with the chemicals in the chemical inventory submitted by the facility. have searched out and evalt ated 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. have reviewed the facility inf Drmation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this facility. I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perforin my inspection. Before beginning the inspect! n, I will review the facility's health and safety information and rules with the ownerimanager and wear the appropriate per onal protective equipment. During the inspection, I will ol serve the labeling and condition of hazardous materials containers and conveyances,the posting of placards and warn ng s!gnage,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 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