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ae1rt 0 • <br /> 3�R�^cOc <br /> t ENVIRONMENTAL HEALTH DEPARTMENT <br /> Donna K.Haran,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 1868 E.Hazelton Ave., Stockton,California 95205 Kaley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellan,R.E.H.S. <br /> JeffCarruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: burger king I. Chemicals Hazards <br /> Address: 4608 waterloo rd ❑Carcinogens: <br /> Contact Person: ®Corrosives: <br /> Phone N: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> N Flammables: <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 /> ❑Taru/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> ®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: ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES []NO ❑None(see below) <br /> Documented Groundwater contamination: ❑YES []NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& Level of Protection: ❑A ❑B ❑C ❑D <br /> describe) ❑Had Hat <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Safety Glassw/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Hearing protection <br /> ❑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 /> PlanPrepared by, Jamie DeLaRosa Date: Dec 12,2012 <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> Plan ApprovDale: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> ed by: <br /> EH 23081(8/21/2012) <br />