Laserfiche WebLink
{ ENVIROIENTAL HEALTH D ARTMENT <br /> +,7ti.11 J OAQUI COUNTY 1 Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kasey <br /> 600 East Main Street, Stockton, California 95202 Obert L. Foley, ,R.E.H.S.Director Robert McClellou,R.E.H.S. <br /> Telephone; (209)468-3420 Fax:(209)468-3433 Jeff 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,4NFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: 31 ❑Carcinogens: <br /> Contact Person: r? ❑Corrosives: <br /> Phone#: co O ❑Dusts: <br /> Proposed Date of investigation/inspection: ✓r i< -' ❑Explosives: <br /> Wlammables: t p <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 �bther s ot 0 e ,f ,CA1r <br /> W <br /> '0azardous Waste inspection El Tiered Permitting inspection /� n S�� J Iowa [.Lwr( <br /> PART III' -�f <br /> 3. Specific Site Information: REQUIRED PIRSONAL PR CTIV E UIP[ENT <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: Ink? El Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks 1 soil contamination: ❑YES ❑NO [ +Igne(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO if monllllllton'ng 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:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) <br /> Hard Hat <br /> Noise Sources: 0 Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑ Flame retardant coveralls <br /> xeavation(falls,trips,slipping,cave-ins): <br /> ❑ <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Heng Protection <br /> ❑Tyvek <br /> ❑,Confined space entry(explosions): ❑ Respirator: C1 APR F1 SCBA <br /> [.Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): 0 Safety vest <br /> Other(specify): Two-way communication} Y <br /> ❑Other(specify): - <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakessects ❑Rodents F1Poisonous Plants PART IV <br /> ❑ <br /> Other/Unknown(specify): PLAN APPROVAL <br /> 8, Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): q <br /> Plan Approved by: v�~ Date: Z <br /> EH 23081(12/16/2011) <br />