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r` <br /> F <br /> Pre-Inspection <br /> Health and Safety Assessment <br /> Facility Name: FA#: <br /> Location: 1 %S�� PRP 52 n i <br /> Business Type: <br /> Initially Completed By: Date: / <br /> Instructions: Fill out this form as best as possible before them ' I 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 /> C mica!Hazards Physical Hazards <br /> Carcinogens: rE Oxygen Deficiency: <br /> ❑ Corrosives: Noise: <br /> ❑ Flammables: Excavations: <br /> ElGases: Climbin : <br /> 11Metals: Explosion: <br /> 11Oxidizers: Heav Equipment: <br /> 11PCBs: Heat or Cold Stress: <br /> ❑ 1 Explosives: • ❑ I Other: <br /> Biological Hazards Personal Protective Equi ment <br /> ❑ Dos Hard Hat ' ❑ CPC-Tyvek <br /> ❑ Snakes Safety Vest ❑ CPC—Other: <br /> ❑ Insects Protective Boots ❑ APR Respirator <br /> ❑ Poisonous Plants Goo les/Glasses ❑ SCBA Respirator <br /> ❑ Other: ❑ Hearing 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 /> have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the <br /> facility. <br /> 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 /> 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 /> 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 /> San Joaquin County Environmental Health Department; 1868 E.Hazelton Avenue;Stockton,CA 95205;209.468.3420 <br /> EHD 48-06-12-2013 Pre-Inspection Health&Safety Assessment <br />