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Pre- Inspection // Health and Safety Assessment Facili Name: SO4O 4 gXY G;.c�:e, , / C FA#: FA00 Location : / & (V / Q �' , �' c449 � Z� "PRM PRO Business Type: 6 LOI& VV ,' Initially Completed By: Robert Lopez Date: 4 4f Z/ 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 : ❑ Oxygen Deficiency: ❑ Corrosives: ❑ Noise : ❑ Flammables: a- ❑ Excavations : ❑ Gases : ' ❑ Climbing : ❑ Metals : A P AO ❑ Ex losion : ❑ Oxidizers : I OX El Heavy Equipment: ❑ PCBs : ❑ Heat Stress : ❑ Explosives , ❑ Cold Stress: Other: ❑ Other: Bio o ical Hazards Personal Protective Equipment ❑ Dogs X Hard Hat ❑ CPC - T vek ❑ Snakes X Safety Vest ❑ CPC - Other: ❑ Insects X Protective Boots 11 APR Respirator ❑ Poisonous Plants X Goggles/Glasses ❑ SCBA Respirator ❑ Other: X HearingProtection ,� Other: Q16 c: t Laa 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 : 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 Robert Lopez 2 ( San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton , CA 95205 ; 209 .468 . 3420 EHD 48- 08-12-2013 Pre-Inspection Health & Safety Assessment