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0 Pre-Inspection Air ,`Health and Safety Assessment Facility Name: ,DC7 r r T FA#: Location: J `r PR#: Business Type: A i r Cpl Initially Completed By: Date: Instructions: Fill out this form as best as possible before the initi I 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 Ph ical Hazards rE] Carcino ens: ❑ Ox en Deficient : Corrosives: Noise: Flammables: xcavations: Gases: 11Climbing: Metals: El Explosion: ❑ Oxidizers: D—rfleavy Equipment: ❑ PCBs: eat or Cold Stress: ElExplosives: ❑ Other: Biological Hazards Personal Protective Equipment ❑ Dogs Hard Hat ❑ CPC-T vek ❑ Snakes —Safety Vest ❑ CPC—Other: ❑ Insects Protective Boots ❑ APR Respirator ❑ Poisonous Plants Goggles/Glasses ❑ SCBA Respirator ❑ Other: Hearing Protection ❑ I 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 wit the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluated information on the pro erties of the chemicals at the facility, using the internet and other resources, for chemicals I am not familiar with at this time 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 cond tion of hazardous materials containers and conveyances, the posting of placards and warning signage, and the actions f the facility employees and guests to identify any potential unsafe conditions that may arise during the inspection. Staff Signature Date Staff Signature Date zs- z Revised:04-15-2013