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Pre-Inspection <br /> ` y1y� <br /> Health and Safety Assessment <br /> Facility Name: \��`� rr r l`ti�'+ sC"xwx FA#:C� <br /> Location: ?i2gL I✓- rWtISOrl W PR#: OS-3q 5.S <br /> Business Type: (,e <br /> Initial) Completed By: I VD Date: Sf!� <br /> Instructions: Fill out this form a&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.Updatelcomplete form as needed.Sign and date below. <br /> Chemical Hazards Ph sical Hazards <br /> ❑ Carcin ens: ❑ Oxygen Deficiency: <br /> ❑ Corrosives: ❑ Noise: <br /> Flammables: U496 of ❑ Excavations: <br /> ❑ Gases: ❑ Climbing: <br /> ❑ Metals: ❑ Explosion: <br /> ❑ Oxidizers: ❑ Heavy Equipment: <br /> ❑ PCBs: ❑ Heat or Cold Stress: <br /> ❑ 1 Explosives: ❑ 1 Other: <br /> Biological Hazards Personal Protective E ui ment <br /> ❑ Dos ❑ 1 Hard Hat ❑ CPC-Tyvek <br /> ❑ Snakes 5P I Safety Vest ❑ CPC—Other: <br /> ❑ Insects Protective Boots ❑ APR Respirator <br /> ❑ Poisonous Plants ❑ Go les/Glasses ❑ SCBA Respirator <br /> ❑ Other: ❑ Hearih 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 intemet 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 /> off Signature Date Staff Signature Date <br /> f� <br /> San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue;Stockton, CA 95205;209.468.3420 <br /> EHD 48-06-12-2013 Pre-Insped m Health 6 Safety Assessment <br />