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Name: Stockton Nissan <br />0 0 <br />Pre -Inspection <br />Health and Safety Assessment <br />y:F:3 <br />Location: 3077 E Hammer Lane, Stockton PR#: 528320 <br />BusinessTvoe: Auto Repair <br />Initially rmmnlatad Aw t,Arrptt RarkiJS Date: Oct 4. 2013 <br />Instructions: Fill out this form as best as possible before the 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. Update/complete form as needed. Sign and date below. <br />Chemical Hazards Ph sical Hazards <br />Carcinogens: ❑ Oxygen Deficiency: <br />❑ Corrosives: ® Noise: <br />❑ Flammables: ❑ Excavations: <br />❑ Gases: ❑ Climbing: <br />❑ Metals: ❑ Explosion: <br />❑ Oxidizers: ® Heavy Equipment: vehicle lifts <br />❑ PCBs: ❑ Heat or Cold Stress: <br />❑ Explosives: ❑ Other: <br />Bio lo ical Hazards Personal Protective E ui ment <br />❑ <br />Dos 1 ® Hard Hat ❑ CPC - T vek <br />❑ <br />Snakes ® I Safety Vest ❑ CPC —Other: <br />❑ <br />Insects 01 Protective Boots ❑ APR Respirator <br />❑ <br />Poisonous Plants 01 Goggles/Glasses ❑ SCBA Respirator <br />❑ <br />Other: N1 Hearinq Protection ❑ 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 ins ection. <br />Sta,ff Sign ure <br />Date <br />Staff Signature <br />Date <br />San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, UA 9b;=; ZW.4bb.841U <br />EHD 48- 06-12-2013 Pre-Inspedon Health & Safety Assessment <br />