Laserfiche WebLink
0 V <br />Pre -Inspection <br />Health and Safety Assessment <br />(no FA#: DD6 3gif <br />u° PR#: 023 <br />nitially Completed BI: ' <br />Instructions: Fill out this form s 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 />❑ Gases:Y ❑ <br />❑ Metals: <br />Li <br />Heat or <br />Other: <br />❑ I CPC - <br />ENIZI <br />LJ I-osonuuS netw <br />❑ Hearing Protection ❑ ter: <br />u 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 safetv related information. <br />I have reviewed the properties and hazards associated wfm the chemicals in the chemical inventory submitted by the <br />facili . <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 safet <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/manage <br />and wear thea ro riate ersonal rotective a ui ment. <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 mai ma ansa uuuuy thv 1110 VVU--,. <br />Staff Signature Date <br />� l5 <br />Staff Signature <br />Date <br />r __ <br />pan c u��on o Avenue[ Stockton. CA 95205; 209.468.3420 <br />San JOagllln WWLL`f ChhvtuhnhhcIuai I ,,,,r ...... _... , .___ _. <br />EHD 48- 06-12-2013 <br />Pre -Inspection Health & Safety Assessment <br />