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Pre- Inspection Health and Safety Assessment Facility Name: NGt ( GI f LIM S 4 I ZS 441 FA#: O U 2k 44 (P Location : ZC1t{ O - Marl e0s Gt Qol • ,moo GV+V rl � � PRM U9 �A fit{ � Business Type : Z w rrt&IQ,RJ `_t�lr�' Initially Completed By: 61t 41 n A F ( 0 li�i c P"ERS Date: (O 1 � 2�0 Instructions : Fill out this form as best as possible before the initial inspection and complete the remaining information during or after the inspection . Subsequent Inspections : 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 prior to conducting the inspection activity. Update/complete form as needed . Sign and date below. Chemical Hazards Physical Hazards ❑ Carcinogens : ia mmme Qaie. nftta ❑ Oxygen Deficiency : Corrosives : tL 6AjwjVASJ4Noise : Flammables : ❑ Excavations : ❑ Gases : ❑ Climbing : ❑ Metals : ❑ Explosion . IX Oxidizers : IZ Heavy Equipment : ❑ PCBs : 19 Heat or Cold Stress : ❑ Explosives : ❑ Other: Bio lo ical Hazards Personal Protective Equipment Dos K Hard Hat ❑ CPC - T vek ❑ Snakes 0 Safety Vest ❑ CPC — Other : Insects ya Protective Boots ❑ APR Respirator Poisonous Plants 9Q Goggles/Glasses ❑ SCBA Respirator IK Other: V1 Hearing Protection Other: to ( oV'8S , By signing below, I am declaring that I have reviewed the health and safety information for this facility pri r to my � n inspection and that I 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 other health and safety related information . I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the facility . I have searched out and evaluated 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 information 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 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 personal 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 arise during the inspection . Staff Signature Date Staff Signature Date San Joaquin County Environmental Health Department; 1868 E . Hazelton Avenue ; Stockton , CA 95205 ; 209 . 468 , 3420 EHD 48- 06-12-2013 Pre-Inspection Health & Safety Assessment