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PgU(N <br /> z z ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;Foai'�� Donna K. Haran,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> ��`�� <br /> Address: Carcinogens: QW C <br /> Contact Person:: '07 11 F]Corrosives: <br /> Phone#: b YJ 7 SS fU Id-MA �– <br /> Proposed Date of investigation/inspection: U l) ❑Explosives: <br /> ❑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 /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> rlwbazardous Waste inspection ❑Tiered Permitting inspection <br /> 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: (h&Pzz ��(,S ❑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:(✓all that apply&describe) Level of Protection: ❑A ❑ B ❑C E D <br /> ❑Heat or Cold Stress: °F high ambient temp.) ®Hard Hat <br /> Ooise Sources: (yea f pj6 ®Safety Glasses/Goggles <br /> xygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Hea equipment h s al in A/P Cartridge: <br /> vy eq p (p y jury&�uma�resulting from moving <br /> equipment): f���VIQ,{,A� l i I lf�- ®Safety vest <br /> -- �— <br /> ❑Other(specify): Two-way communication el-11 <br /> ❑Other(specify): C <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: 41.A X� Date: (0�z � <br /> e.g.,power lines,integrity of dikes,terrain,etc.): `..� <br /> Plan Approved by: Date: 1 o'ks-10 <br /> EH 23081(8/6/2010) <br />