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Pre - Inspection Health and Safety Assessment Facilit Name: Ues v r IIS4eA " 0. 1 SU FAM FA00 Location : t(loj E , (Act.T PRO 11 -� Business Type: M eA i Lcxe" j, 4 .e ,,, - S u � a ,�✓- Initially Completed By: Robert Lopez Date: 7 2 Instructions : Fill out this form as best as possible before the initial inspection and complete the remaining information during 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- should be taken prior to conducting the inspection activity. Updatelcomplete form as needed. Sign and date below. Chemical Hazards Physical Hazards ❑ Carcinogens : ❑ Oxygen Deficiency: ❑ Corrosives : ❑ Noise: ❑ Flammables : ❑ Excavations : Gases : ❑ Climbing : ❑ Metals : ❑ Explosion : ❑ Oxidizers : ❑ Heavy Equipment: ❑ PCBs : ❑ Heat Stress : ❑ Explosives : ❑ Cold Stress: ❑ Other: Other: ` GCA�. C4 Biological Hazards Personal Protective Eqdlpment ❑ Dogs X Hard Hat ❑ CPC - T vek ❑ Snakes X Safety Vest ❑ CPC — Other: ❑ Insects X Protective Boots ❑ APR Respirator ❑ Poisonous Plants X Goggles/Glasses ❑ SCBA Respirator ❑ Other: X Hearing Protection ❑ Other: By signing below, I am declaring 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 the facility file for information on the business type of operation , compliance history , prior releases and response, and other 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 facility. 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 facility's health and safety information and rules with the owner/manager and wear the appropriate 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 conditions that may arise during the inspection . Staff Signature gate Staff Signature Date Robert Lopez 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