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iPre -Inspection 46 <br />uenl+h and Safetv Assessment <br />Business 1 e: v i iz f • •" <br />V Date: G! / <br />nitiall Com feted By: <br />Instructions: Fill out this form est 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 miliar with potential hazardous substances and/or conditions at the facility and any control or precautionary <br />fa <br />measures that should be taken prior to conducting the inspection activity. Updatelcomplete form as needed. Sign and date below. <br />Ila <br />19" <br />n <br />IN <br />❑ 1 Heat or <br />❑ 1 Other: <br />- Other: <br />❑ Poisonous Nlants ❑ Hearin Protection 1 ❑ 1 Other: <br />❑ 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 res onse, and other health and safet related information. <br />�,„o •o„lo tiA t tha nrooerties and hazards associated with the chemicals in the chemical inventory submitted by the <br />I have searched out and evaluated <br />other resources, for chemicals I am <br />I have reviewed the facility informal <br />precautions needed for this facility. <br />I have gained an awareness of the <br />precautions needed to perform my <br />Before beginning the inspection, I v <br />ion on the properties <br />Mar with at this time. <br />my supe <br />review <br />at the <br />of the chemicals at the facility, using tt <br />A not determine the most appropriate <br />iy and have determined the appropriatf <br />and safety information and rules with t <br />internet and <br />health and safety <br />and wear thea ro riate ersonal rotecuve r u. iirciii• <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. ff c;,..,a+ ro Date <br />Staff <br />Department; <br />EHD 48- 06-12-2013 <br />Sta <br />E. Hazelton Avenue; <br />CA 95205; 2UU.00-141V <br />Pre -Inspection Health 8 Safety Assessment <br />