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Pre-Inspection Health and Safety Assessment Facility Name: ILb FA#: u()O& ' \ /C l Location: �/ - PR#: SZ A Business Type: Initially Completed By: Date: '� s Instructions: Fill out this form as best as possible before the initial inspection and complete the remaining i formation during or after the inspection. Subsequent In sections: Review facility file and chemical inventory information, along with the information on this form, to become familiar with p Dtential 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: 01 Oxygen Deficiency: ❑ Corrosives: ❑ Noise: M Flammables: ❑ Excavations: ❑ Gases: ❑ Climbing: ❑ Metals: ❑ Explosion: ❑ Oxidizers: OP Heav E ui ment: G d ❑ PCBs: ❑ Heat or Cold Stress: ❑ I Explosives: ❑ Other: Biological Hazards Personal Protective E uipment ❑ Dos ❑ Hard Hat ❑ CPC-T vek ❑ Snakes Safety Vest ❑ CPC—Other: ❑ Insects Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Goggles/Glasses ❑ SCBA Respirator ❑ Other: ❑ Hearing Protection ❑ Other: By signing below, I am declz ring 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 he 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 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 internet and other resources, for chemicals I am not familiar with at this time. I have reviewed the facility information with my supervisor if I could not determine the most appropriate health and safety precautions needed for this fa 'lity. 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 inspectio , I will review the facility's health and safety information and rules with the owner/manager and wear the appropriate pers nal protective equipment. During the inspection, I will obr,erve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warnin j signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may ari a during the inspection. ?MNneture Date Staff Signature Date San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton,CA 95205;209.468.3420 EHD 48-06-12-2013 Pre-Inspection Health&Safety Assessment