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Pre -Inspection <br />Health and Safety Assessment <br />Facility Name: Safeway Store 1769 FA#: FA0012734 <br />Location: 2808 Country Club Blvd PRM PR0538350 <br />BusinessTYne: Hazardous Waste Generator <br />Inally Completed By: Ellanna FlOrldOI REHS Date: 6/16/2020 <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 />Chemical Hazards <br />Physical Hazards <br />❑ <br />Carcinogens: 6"cN j+r4e. rr vla <br />❑ <br />Oxygen Deficiency: <br />® <br />Corrosives: 4v)c V14Z WAM <br />® <br />Noise: <br />® <br />Flammables: <br />❑ <br />Excavations: <br />❑ <br />Gases: <br />❑ <br />Climbing: <br />❑ <br />Metals: <br />❑ <br />Explosion: <br />® <br />Oxidizers: <br />® <br />Heavy E ui ment: <br />❑ <br />PCBs: <br />® <br />Heat or Cold Stress: <br />❑ <br />Explosives: <br />❑ <br />Other: <br />Bio <br />lo ical Hazards <br />Personal Protective Equi ment <br />® <br />Dos <br />Hard Hat <br />❑ <br />CPC - T vek <br />❑ <br />Snakes <br />Safety Vest <br />❑ <br />CPC — Other: <br />® <br />Insects <br />Protective Boots <br />❑ <br />APR Respirator <br />❑ <br />Poisonous Plants <br />® <br />Goggles/Glasses <br />❑ <br />SCBA Respirator <br />® <br />Other: COVID-19 virus <br />Hearing Protection <br />® <br />Other: nitrile gloves, face <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 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 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 />b/l�l2a <br />San Joaquin County Environmental Health <br />Department; 1868 <br />E. Hazelton Avenue; Stockton, <br />CA 95205; 209.468.3420 <br />EHD 48- 08-12-2013 Pre -Inspection Health &Safety Assessment <br />�vPX�n� <br />