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Facility Name: H V 5V <br />Pre -Inspection <br />Health and Safety Assessment <br />n&*1t*0n Sup(�ly - <br />FA#: 0 U -1 <br />Location: i K9 (0 S W i on �il�G S 1 u (**Yi , • Ci PR#: 0 5 3 (O <br />Business Type: A om INA.S+t &%aywh r <br />Initially Completed Bv: el 1(A vt ra FIo v k0 , ? M Date: (D 0 tI i 2U 20 <br />Instructions: Fill out this form as 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. Update/complete form as needed. Sign and date below. <br />San Joaquin County Environmental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 <br />EHD 48- 06-12-2013 Pre -Inspection Health &Safety <br />Chemical Hazards <br />Physical Hazards <br />❑ <br />Carcinogens: M: (m 4t reolViaie <br />❑ <br />Oxygen Deficiency: <br />4 <br />Corrosives: G H WAA, <br />V <br />Noise: <br />Flammables: <br />❑ <br />Excavations: <br />19 <br />Gases: <br />❑ <br />Climbing: <br />Metals: <br />❑ <br />Explosion: <br />t4 <br />Oxidizers: <br />Heavy Equipment: <br />❑ <br />PCBs: <br />19 <br />Heat or Cold Stress: <br />❑ <br />Explosives: <br />❑ <br />Other: <br />Bio <br />lo ical Hazards <br />Personal Protective Equipment <br />Dos <br />K <br />Hard Hat <br />❑ <br />CPC - T vek <br />❑ <br />Snakes <br />4 <br />Safety Vest <br />❑ <br />CPC — Other: <br />Insects <br />Protective Boots <br />❑ <br />APR Respirator <br />❑ <br />Poisonous Plants <br />Goggles/Glasses <br />❑ <br />SCBA Respirator <br />14 <br />Other: CO1/1 9 � I CL ViYik <br />Hearing Protection <br />Other: 11i;Y1V <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 response, and other health and safety related information. <br />I have reviewed the properties and hazards associated with the chemicals in the chemical inventory submitted by the <br />facility. <br />I have searched out and evaluated information on the properties of the chemicals at the facility, using the internet and <br />other resources, for chemicals I am not familiar with at this time. <br />I <br />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 <br />have gained an awareness of the potential hazards at the facility and have determined the appropriate health and safety <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/manager <br />and wear the appropriate personal protective equipment. <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 that may arise during the inspection. <br />Staff Signature <br />Date <br />Staff Signature <br />Date <br />Lot 11 ZD <br />Assessment <br />