COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Prem [Inspection Health and Safety Assessment Facility Name: 1/ 1 CIO 1440M i c) jh a e✓ ' oi !;y je,4#e Vji C ,ej FAQ#: FA00 Location : Lj (�, O Lt, � jr00 o Zot C �.� 77J� 9SL�f�#: PRO Business Type: Initially Completed By: Robert Lopez Date: Z Instructions : Fill out this form as best as possible before the initial inspection and complete the remaining r 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 thatshould be taken prior to conducting the inspection activity. Update/complete form as needed. Sign and date below. Chemical Hazards Ph sical Hazards ❑ Carcinogens : ❑ Oxygen Deficiency: Corrosives: ❑ Noise : Flammables : ❑ Excavations : ❑ Gases : ❑ Climbing : ❑ Metals : ❑ Explosion : ❑ Oxidizers : ❑ Heavy Equipment: ❑ PCBs : ❑ Heat Stress : ❑ Explosives: ❑ Cold Stress: ,91 Other: ❑ Other: Biological Hazards Personal Protective Equipment ❑ 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 Hearinq Protection ,I9 Other: S 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 . 1 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 ate Staff Signature Date Robert Lopez 7 2 Z San Joaquin County Environmental Health Department; 1868 E . Hazelton Avenue; Stockton, CA 95205 ; 209 .468 . 3420 EHD 46- 06-12-2013 Pre-Inspection Health & Safety Assessment