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Pre-Inspection Health and Safety Assessment Facility Name: Gemco FA#: 0000650 Location: 1022 Frontage Road PR#: 051610$ Business? e: Gasoline Service Station Date: Mar 1$ 2015 Initial) completed B E Manzo Instructions: Fill out this form as best as passible before the initial inspection and complete the remaining information during or after the inspection. Su this cent inspections: Review facility file and chemical inventory information, along with the information on this and/or conditions at the facility and any control or precautionary form, to become familiar with potential hazardous substances measures that should be taken prior to conducting the inspection activity. Updatelcomplete form as needed. Sign and date below, Chemical Hazards Ph sisal Hazards ® Canino ens: ❑ Ox en Deficient : ❑ Corros1ves: ❑ Ncise: ® Flammables: ❑ Excavations: ❑ Gases; ❑ Climbing-_ Metals: ❑ Ex losion: ❑ Oxidizersi 0 Heav E ui manta ❑ PCB_s: 181 Heat or Cold Stress: ❑ Ex losives: ❑ Other: Biolo ical Hazards Personal Protective Ecivii ment . Dos ❑ Hard fiat ❑ GPC-7 vek ❑ Snakes N Safet Vest ❑ CPC—Other: ® Insects N Protective Boots ❑ APR Res irator ❑ Poisonous Plants ❑ Go les/Glasses ❑ SCBA Res irator ❑ Hearino Protection F1 Othe ❑ Other: r: By signing below, I ant 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 safetyrelated information. I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the Facilit . 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 m inspection. Before beginning the inspection, l will review the facility's health and safety information and rules with the ownerlmanager and wear theappropriate ersonal rotective aqui went. During the in, I will observe the labeling and condition of hazardous materials containers and conveyances, khe 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 San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 Pre-Inspection Heaith&Safety Assessment EH©48- 06-12-2613