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Pre-Inspection Health and Safety As essment FacilityName: ` ° FA#: n Location: d P Business Type: 6 t Initial) Completed BY: Date: Instructions: Fill out this formas best as possible before the initial inspect' a d complete the remaining i or tion ring or after the inspection. Subse vent Ins ections: Review facility file and chemic entory 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 p for 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: ❑ Ex losion: ❑ Oxidizers: ❑ Heavy Equipment: ❑ PCBs: ❑ Heat or Cold Stress: ❑ 1 Explosives: ❑ Other: Bio lo ical Hazards Personal Protective Equipment ❑ Dos ❑ Hard Hat ❑ CPC-T vek El Snakes El Safety Vest ❑ CPC-Other: El Insects El Protective Boots ❑ APR Respirator El Poisonous Plants ElGoggles/Glasses ❑ SCBA Respirator El Other: ElHearing 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 p rformed, 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 evaluted information on the properties of the chemicals at the facility, using the internet and other resources,for chemicalsi am not familiar with at this time. I have reviewed the facility info mation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this fac lit . I have gained an awareness o the potential hazards at the facility and have determined the appropriate health and safety precautions needed to erform my inspection. Before beginning the inspectiotal-protective-equipment.—I will review the facility's health and safety information and rules with the owner/manager -and-wear-the-appropriate- ei -- — -- During the inspection, I will observe the labeling and condition of hazardous materials containers and conveyances,the posting of placards and warnino signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that mayari during the inspection. Staff Signature Datq Staff Signature Date San Joaquin County Envirnmental Health Department; 1868 E. Hazelton Avenue;Stockton, CA 95205;209.468.3420 EHD 48-06-12-2013 Pre-Inspection Health&Safety Assessment