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�q.4Ay'N1'.co < 00 0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY Program Coordinators oaaa K. R.E.H.S. Director 600 East Main Street, Stockton,California 95202 Kaley L.Foley,R.E.H.S. Telephone: (209)468-3420 Fax:(209)468-3433 Robert McCletlon,R.E.H.S. JeffCmruesco,R.E.H.S. Web:www.sjgov.org/ehd SITE HEALTH& SAFETY PLAN PART PART II GENERALS E INF RMA/.•I"TIO J ' / EVALUATION OF POTENTIAL HAZARDS 1. Site Nam `yY�� 3j�( 1. Chemicals Hazards Address: U� 5� :�.{. Carcinogens: Contact P on: 'S) 'L Corrosives: Phone#: qM "Dusts: Proposed to of investigation/inspection: 2 Explosives: ❑Flammables: 2. Descriptic and brief narrative of inspection activity: ❑Inorganic Gases: C3New T installation ❑UAR Investigation ❑Metals: ❑Tank losure in Place C3nk/ Tank/Pipe Repair ❑Oxidizers: ❑Tank/ 'pe Removal ElRe-excavation ❑PCBs: C1I Sampl g ❑Boring/Monitoring Well installation ❑Other: H us Waste inspection ❑Tiered Permitting inspection PART III 3. Specific to Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Con t: Tank Age: operations unless appropriate rationale or restrictions we provided): Other: ❑Combustible Gas/Oxygen Meter ,� /, /�'}��/�� ❑Detector Tubes(specify): 4. Type of eration:j U" ' '"0 P ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release H story: ❑Other(specify): Evidence if leaks/soil contamination: ❑YES kNO ❑None(see below) Documcni ed Groundwater contamination: []YES 5;RJO If monitoring instruments are not used,rationale or activity/area restrictions: Backgrou d and description of any previous investigation or incidence: 2. Personal Protective Equipment 6. Potential 11 ealth&Safety Physrca Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D Heat or Cold Stress:�°F(high ambient temp.) ®Hard Hat Noise Sources: ®Safety Glasses/Goggles ®Steel toed/shank shoes or boots ElOzyg Deficiency: C]Excav tion(falls,trips,slipping,cave-ins): F-1 Flame retardant coveralls ®Hearing protection C]Hand g and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek ,,,❑,,,��//////Co ed space entry(explosions): C]Respirator: [I APR C]SCBA t Heavyequipment(physical injury&trauma resulting from moving A/P Cartridge: // equip t): ®Safety vest ❑Other specify): ❑Two-way communication ❑Other(specify): 7. Anticipat Biological Hazards: ❑Snak Insects ❑Rodents ❑Poisonous Plants PART IV ❑Other nknown(specify): PLAN APPROV I 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: I` e.g.,power lines,integrity of dikes,terrain,etc.): k A,,I( (, Plan Approved by: V r�`r Date: EH 23081(6/2 /2010)