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• Pre-Inspection 9 Health and Safety Assessment Facility Name: CIRCLE K/76 FA#: FA Location: 1469 E HAMMER LN PR#: PR Business Type: GAS STATION Initially Completed By: LOWELL ALLEN Date: 9/17/13 Instructions: Fill out this form as hest 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: ❑ Explosion: ❑ Oxidizers: ❑ Heavy Equipment: ❑ PCBs: ❑ Heat Stress: ❑ Explosives: ❑ Cold Stress: ❑ 1 Other. 01 Other: Biolo ical Hazards Personal Protective E ui ent ❑ Dogs ❑ Hard Hat ❑ CPC-Tyvek ❑ Snakes ❑ Safety Vest ❑ CPC—Other: ❑ Insects ❑ Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Goggles/Glasses ❑ SCBA Respirator ❑ Other: ❑ 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. 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, / 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 I [- Qom... 1-11;n r`n nh, L1. 11h rl......d.. +. 1000 C L1..-. 1. ^n A....-- 04...-L1n !`A ng'=-')nn AGO OAOn