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• o.PAuIN c <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 1868 E. Hazelton Ave., Stockton,California 95205 Robert McClellon,R.E.H.S. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 ,teff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. site Name: United Facilities Inc 1. Chemicals Hazards <br /> Address: 3535 Perlman Ave., Stockton 95206 ❑Carcinogens: <br /> Contact Person: Brian Jorgensen ®Corrosives: Fork lift batteries <br /> Phone q: 209-982-5580 ❑Dusts: <br /> Proposed Date of investigation/inspection: 11/1/2012 ❑Explosives: <br /> ®Flammables: Propane <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation M Other: Combustible: Diesel fuel <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> M Hazardous Materials Business Plan PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation:General Warehousing ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO M None(see below) <br /> Documented Groundwater contamination: ❑YES []NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> I will not be handling or opening hazardous material <br /> Background and description of any previous investigation or incidence: storage containers. <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& Level of Protection: EIA ❑B ❑C ED <br /> describe) M Hard Hat <br /> ❑Heat or Cold Stress: -F(high ambient temp.) M Safety Glasses/Goggles <br /> ❑Noise Sources: M Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Hearing protection <br /> M Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): ❑Two-way,communication <br /> ❑Other(specify): ❑Other(specify): <br /> 7. Anticipated Biological Hazards: PART IV <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> Plan Prepared by: Robert Lopez Dale: 11/1112 <br /> 8. Narrative(provide all information which could impact Health and Safety, C r1 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved by: 2.A Date: l� L/ <br /> EH 23081(821/2012) <br />