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a?'4A�a fog <br /> a <br /> ENVIRONMENTAL HEALTH APARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> Donna KDirector R.E.H.S. Kasey1868 E. Hazelton Ave., Stockton, California 95205 Robert L.Foley, ,R.E. S. <br /> Robert McClellan,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 /> Rodney Estrada,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,R.E.H.S. <br /> PARTI PARTII <br /> GENERAL SITE FORM T 0 EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: I.ZC � 1. Chemicals Hazars /� <br /> Address: �JY- )Carcinogens:6CQ <br /> ✓bKb0 i &F, AJ/1177V'OL[ Z� <br /> Contact Person: ❑Corrosives: <br /> Phone#: P' ❑Dusts: <br /> Proposed Date of investigation/inspection: — /I ❑Explosives: <br /> tdFlammables:LIP76WAJO'T(,�(tQ Q741&ZRe <br /> 2. Description and brief narrative of inspection activity: N0Inorganic Gases: C/M <br /> E]New UST installation ❑UAR Investigation ❑Metals: c� V <br /> El Tank Closure in Place ❑Tank/Pipe Repair Zf Oxidizers:>-UGLP.n <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: r� <br /> El Sampling ❑Boring/Monitoring Well installation �ther: 17, r <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> ❑Hazardous Materials Business Plan PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: I. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other: ❑Detector Tubes(specify): <br /> F /- ❑Photo ionization Detector <br /> 4. Type of Operation:sk' d L�/l�� b�� ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of my previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C XD <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& Hard Hat <br /> describe) afety Glasses/Goggles <br /> ❑Heat or Cold Stress: °F(high ambient temp.) >1Steel toed/shank shoes or boots <br /> ❑Noise Sources: ❑Flame retardant coveralls <br /> ❑Oxygen Deficiency: Hearing protection <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Tyvek <br /> "f;Leklandling and Transfer of a Hazardous Substance(fire,explosions,etc.): ❑Respirator: ❑APR ❑SCBA <br /> A/P Cartridge: <br /> ❑Confined space entry(explosions): ❑Safety vest <br /> Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication <br /> equipment): — ❑Other(specify): <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: PART IV <br /> PLAN APPROVAL <br /> ❑Snakes Insects ❑Rodents El Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared b : i------�� Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, plan Approved by: Date: J <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> EH 23081(1/22013) <br />