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9 4 Pre-Inspection // , � Health a/nd/Safety Assessment Fadlllty Name ,�GIlQ,SXQc1� V �CL�T�//< IwoFA#: Location 113-7 S jj!f2lJ f d ZJV7.7 PR#: Business T e: rS� Initial) Completed By: ✓ Date: 3 3 Instructions: Fill out this form s best as possible before the initial inspection and complete the remaining information during or after Ile inspection. Subsequent Insoections: 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. Updatelcomplete form as needed.Sign and date below. Chemical Hazards Ph sical Hazards Carcino ens: ❑ Ox en Deficiency: ❑ Corrosives: ❑ Noise: Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ Metals: ❑ Ex losion: ❑ Oxidizers: Heav E ui menta V ❑ PCBs: ❑ Heat or Cold Stress: ❑ Ex losives: ❑ Other: Personal Protective E ui ment Biolo ical Hazards ❑ Do s E] Hard Hat [3 CPC-T vek ❑ Safet Vest ❑ CPC—Other: ❑ Snakes Protective Boots ❑ APR Res irator ❑ Insects Go les/Glasses ❑ SCBA Res irator ❑ Poisonous Plants 171Hearin Protection ❑ Other: ❑ 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 res onse, and other health and safet related 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 recautions needed to erform m ins ection. Before beginning the inspection, I will review the facility's health and safety information and rules with the owner/manager and wear the a ro riate ersonal rotective a ui 3ment. During the inspection, I will observe the labeling and condition of hazardous materials containers and conveyances,the posting of placards and warning signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that ma arise durin the ins ecDate Staff Signature Date ' Staff ature 6 1,3e l San Joaquin County Environmental Health Departmen1; 1868 E. Hazelton Avenue;Stockton,CA 95205;209.468.3420 Pre-Inspection Health&Safety Assessment EHD 48. 06-12-2013