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aqurry ENVIRONMENTAL HEALTH DL-PARTMENT • C4�+Fo. �.i�p SAN JOAQUIN COUNTY Program Coordinators Donna K.Heran,R.E.H.S. Kase L. Co R.E.H.S. Director 600 East Main Street, Stockton,California 95202 Y Y, Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. Jeff Carruesco,RE.H.S. Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. SITE HEALTH& SAFETY PLAN PART I PART H GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1. Chemicals Hazards /J Address: Carcinogens: Contact Person: 0-A 1 A/L0V-Z7C? LJ Corrosives: Phone#: — �D ❑Dusts: Proposed Date of investigation/inspection: 14 1.5 — ( "2 ❑Explosives: �.Flammables: 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: ❑New UST installation ❑UAR Investigation Metals: n n ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizers: ufiWl ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation ❑Other: ❑Hazardous Waste inspection ❑Tiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other.: ❑Combustible Gas/Oxygen Meter aa E3Detector Tubes(specify): 4. Type of Operation: �i� a_ [IPhoto ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO C$&e(see below) Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any previous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D ❑Heat or Cold Stress: OF(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots excavation(falls,trips,slipping,cave-ins): C]Flame retardant coveralls Handling and Transfer of a Hazardous Substance(fire,explosions,etc.); ®Hearing protection [I Tyvek E]Confined space entry(explosions): El Respirator: E]APR C]SCBA Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): NCTwo-way communication ❑Other(specify): 7. Anticipated Biological Hazards: nakes Xhrsects Rodents C]Poisonous Plants PART IV U—Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b e: l A� e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved by: rU Date: EH 23081(3/5/2012)