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r.)o44 c�`y <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> �acrFsRa;P SAN JOAQUIN COUNTY ProgramCoordinalors <br /> Direrectorctor <br /> Donna K.H RE.H.S. 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S.Telephone: (209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.H.S. <br /> 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 INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name- rzL 1. Chemicals Hazards <br /> Address: �Oi <br /> LAA ❑Carcinogens: , <br /> Contact Person: AA, (art IU5ElCorrosives: <br /> Phone N: ❑Dusts: <br /> Proposed Date of investigation/inspection:�Z�2i ( ❑Explosives: <br /> R4 foffd Nb AN AP� tv� ❑Flammables: l �(gLA��� <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases:0,d(yQA4 LP, lA/kva� p]de. <br /> ❑New UST installation ❑GAR Investigation ❑Metals: T_T <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ������x--❑---,,,,,,......aaa���S""""""ampling El Boring/Monitoring Well installation El Other: <br /> 'P_Pazardous Waste inspection ❑Tiered Permitting inspection <br /> El <br /> 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: /A.(dl "Dku ❑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 LINO 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:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Hardaes�w�ashioeEsor <br /> ❑Noise Sources: Safeoots <br /> ❑Oxygen Deficiency: <br /> E]Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. <br /> ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: L tr <br /> e.g.,power lines,integrity of dikes,terrain,etc.): r/{l� <br /> Plan Approved by: t Date: G v <br /> EH 23081(6/14/2012) <br />