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Pre-inspection <br /> Health and Safety Assessment <br /> Facility Name: AA vc�,(no o A7 CO o—"\&)� OAc\A FA#: 03 9 d <br /> Location: 10,�O r &P'lo Oc PR#: C)I� <br /> Business Type: <br /> Initially Completed By: Date: <br /> Instructions: Fill out this form as best as possible before\te' initial inspection and complete the remaining information during or after <br /> the inspection. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this <br /> form, to become familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary <br /> measures that should be taken prior to conducting the inspection activity. Updatelcomplete form as needed.Sign and date below. <br /> Chemical Hazards Physical Hazards <br /> A I Carcinogens: 0 Oxyqen Deficiency: <br /> 0 Corrosives: 19 Noise: <br /> El Flammables: 0 Excavations: <br /> 0 Gases: 0 Climbing: <br /> El Metals: El Explosion: <br /> El Oxidizers: NJ Heavy quipment: <br /> El PCBs: El I Heat or Cold Stress: <br /> El I Explosives: 01 Other: <br /> Biological Hazards Personal Protective Equipment <br /> 0 Dogs 'K[I Hard Hat 0 CPC-Tyvek <br /> El Snakes �R Safety est 0 CPC—Other: <br /> El Insects IISI, Protective Boots El APR Respirator <br /> El Poisonous Plants Goggles/Glasses 0 SCBA Respirator <br /> El Other: I& Hearing Protection 0 Other: <br /> By signing below, I am declaring that I have reviewed the health and safety information for this facility prior to my <br /> inspection and that I have performed, and will perform during the inspection, the following actions: <br /> I have reviewed this form and the facility file for information on the business type of operation, compliance history, prior <br /> releases and response, and other health and safety related information. <br /> I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the <br /> facility. <br /> I have searched out and evaluated information on the properties of the chemicals at the facility, using the internet and <br /> other resources, for chemicals I am not familiar with at this time. <br /> I have reviewed the facility information with my supervisor if I could not determine the most appropriate health and safety <br /> precautions needed for this facility. <br /> I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety <br /> precautions needed to perform my inspection. <br /> Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager <br /> and wear the appropriate personal protective equipment. <br /> During the inspection, I will observe the labeling and condition of hazardous materials containers and conveyances, the <br /> posting of placards and warning signage, and the actions of the facility employees and guests to identify any potential <br /> unsafe conditions that may arise during the inspection. <br /> Staff Signature Date Staff Signature Date <br /> CA-d <br /> San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton,CA 95205;209,468.3420 <br /> EHD48- 06-12-2013 Pre-Inspectlion Health&Safety Assessment <br />