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4( Pre -Inspection 0 Health and Safety Assessment Instructions: Fill out this form as st as possible before the initial inspection and complete the remintion uring or after Initial Com leted B . --7needed. the inspection. Subsequent Inspections: Review facility file and chemical inventory information, ainformation on this forth, to become familiar with potential hazardous substances and/or conditions at the facility aol or precautionary measures that should be taken prior to conducting the inspection activity. Updatelcomplete form asn and date below. C emical Hazards Ph sical Hazards Carcino ens: ❑ Ox en Deficienc Corrosives: ❑ Noise: Flammables: ❑ Excavations: limbi :❑ ❑ Gases: ❑ Climb;-- 0Metals: ❑. Ex losion: ❑ Oxidizers: Hea E ui menta ❑ PCBs: Heat or Cold Stress: ❑ Explosives: 01 Other: Bio logical Hazards Personal Protective E ui merd ❑ Dogs ❑ Hard Hat ❑ CPC -T ek ❑ Snakes Safety Vest ❑ CPC—Other: Insects Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Go les/Glasses ❑ SCBA Respirator ❑ Other: ❑ Hearing Protection ❑ 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 response, and other health and safety related information. I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluated information on the properties of the chemicals at the facility, using the intemet and other resources, for chemicals I am not familiar with at this time. I have reviewed the facility information with my supervisor rf I could not determine the most appropriate health and safety needed for this facility. precautions I have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform my inspection. Before beginning the inspection, I will review the facilitys health and safety information and rules with the owner/manager and wear the appropriate pmonal protective equipment. I the labeling and condition of hazardous materials containers and conveyances, the During the inspection, will observe the actions of the facility employees and guests to identify any potential posting of placards and warning signage, and unsafe conditions that may arise duringthe ins ction. Staff Signature Date Staff Signature Date -a-i5 , ,--1,.... Av..n� e•. elrv.rri^n rrA Qpm. %nQ ARR m9n San Joaquin County Environmental Beam uepamnenr, i ow �. naze tun —• • -- EHD 48- 06-12-2013 Pre-Inspedon Health 8 Safety Assessment