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1 Pre- Inspection Health and Safety Assessment Facility Name : IO Ic;"y i4 FA#: FA00 Location : L (o !v �O /�• .cc- � �� l�e %z C l 2/u e. , to j PR#: PRO Business Type: 1,r• R �5 ~ 2 Z 7 Initially Completed By: Robert Lopez Date: 2 Instructions : Fill out this form as best as possible before the initial inspection and complete the remainin6 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 : 2( Flammables: ❑ Excavations : Gases: ❑ Climbin ❑ Metals : ❑ Explosion : Oxidizers : ❑ Heavy Equipment: ❑ PCBs : ❑ Heat Stress : ❑ Explosives : ❑ Cold Stress : ElOther: ❑ I Other: Biological Hazards Personal Protective Equi ment ❑ Dos X Hard Hat ❑ CPC - T vek ❑ Snakes X Safety Vest ❑ CPC — Other: ❑ Insects X Protective Boots ❑ APR Respirator ❑ Poisonous Plants X Goggles/Glasses ❑ SCBA Respirator ❑ Other: X 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 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 . 1 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 lei& 2 San Joaquin County Environmental Health Department; 1868 E . Hazelton Avenue; Stockton , CA 95205 ; 209 .468 . 3420 EHD 48- 06-12-2013 Pre-Insoection Health & Safety Assessment