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Pre-Inspection Health and Safety�\ Assessment � n J Facility Name: / FA#: 7 9 Location: �j L Business Type: l Initially Completed By: C�� N i Date: I — Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining information duri g or after the inspection. Subsequent Ins ections: Review facility file and chemical inventory information, along with the information on this form, to become familiar withp tential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken p for to conducting the inspection activity. Update/complete form as needed.Sign and date below. Chemical Hazards Physical Hazards Carcinogens: ❑ Oxygen Deficiency: ❑ Corrosives: ❑ Noise: Flammables: ❑ Excavations: ❑ Gases: ❑ Climbin : ❑ Metals: ❑ Explosion: ❑ I Oxidizers: ❑ Heavy Equipment: 01 PCBs: ❑ Heat or Cold Stress: 01 Explosives: ❑ I Other: Bio lo ical Hazards Personal Protective E ui ment ❑ 1 Dos M Hard Hat ❑ 1 CPC-T vek ❑ Snakes V& Safety Vest ❑ 1 CPC—Other: ❑ Insects ® Protective Boots ❑ APR Respirator ❑ Poisonous Plants W Goggle /Glasses ❑ SCBA Respirator ❑ Other: ❑ Hearing Protection ❑ Other: By signing below, I am decla 'ng that I have reviewed the health and safety information for this facility prior to my inspection and that I have pe ormed, and will perform during the inspection, the following actions: I have reviewed this form and t e facility file for information on the business type of operation, compliance history, prior releases and response, and of er health and safety related information. I have reviewed the properties nd hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evalued information on the properties of the chemicals at the facility, using the internet and other resources, for chemicals am not familiar with at this time. I have reviewed the facility info_`11ation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this faci ity. I have gained an awareness of he potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform y inspection. Before beginning the inspection I will review the facility's health and safety information and rules with the owner/manager and wear the appropriate perso al protective equipment. During the inspection, I will obs rve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warnin signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may aris during the inspection. StaffSignature Date Staff Signature Date .�Vq la � 0,Is San Joaquin County Enviro imental Health Department; 1868 E. Hazelton Avenue; Stockton,CA 95205;209.468.3420 EHD 48-06-12-2013 Pre-Inspection Health&Safety Assessment