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Pre - Inspection Health and Safety Assessment Facility Name : QO jQ r L—GV4. 1 0 �,S V14 FA#: FA00 Location : �/ �v . Qr 5 � n�� C1 PRM PRO Business Type: Initially Completed By: RobeoLopez _ Date : jfk1 , LL67 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. Update/complete form as needed . Sign and date below . Chemical Hazards Physical Hazards V1 Carcinogens : vSd o ' _ � ❑ Oxygen Deficiency : ❑ Corrosives : ❑ Noise : ❑ Flammables : ❑ Excavations : Gases : wM S" o ❑ Climbing : ❑ Metals : I U ❑ Explosion : ❑ Oxidizers : n Heavy Equipment: ForlLi; ❑ PCBs : ❑ Heat Stress : ❑ Explosives : ❑ Cold Stress : ❑ Other: ❑ Other: Biological Hazards Personal Protective Equipment -11 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 Q Other: Uv � X Hearing Protection M Other: NV,. 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 Date Staff Signature Date R®berHL-o ep�z 30v,q\ k 1r of 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