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Pre-Inspection HealthandSafety Assessment FacilityName: / / Q s , ��-6'"l FA#: ZY 5-7 Location: 02`j Cp 0 S • ��_] z]0�—a do s-t . s'_7'__DC R#: 5 3 - hC 7 E5 Business Type: Initially Completed By: S- Date: 3l Instructions: Fill out this for best as possible before the initial inspection and complete the remaining information during or after the inspection. Subsequent Ins ctions: Review facility file and chemical inventory information, along with the information on this form, to become familiar with po ential 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. Update/complete form as needed. Sign and date below. Chemical Hazards Physical Hazards Carcino ens: 7 ❑ Oxygen Deficiency: ❑ Corrosives: ❑ Noise: ❑ Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ Metals: ❑ 1 Explosion: 01 Oxidizers: HeavyE ui ment: 111 PCBs: ❑ Heat or Cold Stress: 01 Explosives: ❑ Other: Biological Hazards Personal Protective Equipment ❑ Dos ❑ Hard Hat ❑ CPC-T vek ❑ Snakes ❑ Safety Vest ❑ CPC–Other: ❑ Insects jK Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Goggles/Glasses ❑ SCBA Respirator ❑ Other: ❑ Hearing Protection ❑ Other: By signing below, I am declari ig that I have reviewed the health and safety information for this facility prior to my inspection and that I have pedormed, and will perform during the inspection, the following actions: I have reviewed this form and th 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 properties a d hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluatd information on the properties of the chemicals at the facility, using the internet and other resources, for chemicals I trn not familiar with at this time. I have reviewed the facility information with my supervisor if I could not determine the most appropriate health and safety precautions needed for this faciliiy. I have gained an awareness oft a potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform my inspection. Before beginning the inspection, will review the facility's health and safety information and rules with the owner/manager and wear the appropriate person I protective equipment. During the inspection, I will obse a the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warning ignage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may arise uring the inspection. Staff S09,ture Date Staff Signature Date San Joaquin County Environ ental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment