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Pre-Inspection WW Health and Safety Assessment Facility Name: Ak&', Lb 00 J� _ Zi° % L C / FA#: Location: � 5 PR# r Business Type FInitiall Completed By: C� Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining information ring or after the inspection. Subsequent Inspections: 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 Che ical Hazards should be taken prior to conducting the inspection activity. Update/complete form as needed. Sign and date below. Carcinogens: Physical Hazards ❑ orrosives: ❑ Oxygen Deficiency: lammables: ❑ Noise: Gases: ❑ Excavations: ❑ Metals: ❑ Climbing: ❑ Oxidizers: ❑ Explosion: ❑ PCBs: ❑ Heav Equipment: ❑ Explosives: ❑ Heat or Cold Stress: C Biological Hazards ❑ Other: ❑ Dogs Personal Protective Equipment Ire ❑ Snakes Hard Hat ❑ CPC - Tyvek ❑ Insects afety Vest ❑ CPC — Other: ❑ Poisonous Plants Protective Boots ❑ APR Res irator ❑ Other: ❑ Go gles/Glasses ❑ SCBA Res irator ' declaring El Hearing Protection ❑ Other: j By signing below, I am dling 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:peration, compliance history, prior I have reviewed this form and the facility file for information on the business type of oI releases and response, and other health and safety related information. I have reviewed the properties and . .azards facility, associated with the chemicals in the chemical inventory submitted by the I have searched out and evaluated information on theproperties of th e chemicals at the facility, using the Internet and other resources, for chemicals I am not familiar with at this time 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 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 he facility's alth and safety information and rules with the owner/manager and wear the ap ropdate personal protective equipment. 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 cc dition that y arise during the inspection . St f i n ture Date Staff Signature Date 6 Revised: 04-15-2013 ' ' :