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)4�Q CA <br /> ENVIRCSMENTAL HEALTH &PARTMENT <br /> <c'F'pa Program Coordinators <br /> Donna Director RE.H.S. SAN JOAQUIN COUNTY 600 East Main Street,Stockton, California 95202 Kaley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert McClellon,RE.H.S. <br /> leffCarruesco,RE.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART <br /> GENERAL SITE INFORMATIONEVALUATION OF POTENTIAL HAZARDS <br /> me: <br /> 1. Site Nai< r Pe w, I, 1. Chemicals Hazards <br /> Address: is - k' ❑Carcinogens: <br /> , <br /> Contact Person:4 IAIc e.. �ur; <br /> ❑Corrosives: <br /> Phone N: 2:7G; Q 4&j ❑Dusts: <br /> Proposed Date of mvestigation/inspection: 4 , 1,7 —/1 ❑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 ❑TankTipe Repan ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other. <br /> ❑Hazardous 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=less appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> (� /' ❑Detector Tubes(specify): <br /> 4. Type of Operation: M 2.c+( (Gu I 72�(' 6�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 ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency. ®Steel toed/shank shoes or boots <br /> ""��❑Excavation(falls,lips,slipping,cavo-ins): <br /> ❑Flame retardant coveralls <br /> /¢Handling and Transfer of a Hazardous Substance(fire,explosions,em.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑bisects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROV <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan PMar by, /' G� �( <br /> e.g.,Power lines,integrity of dikes,terrain,etc.): Y Date: <br /> Plan Approv by: QAAk <br /> yk— Date: �1 <br /> I <br /> i <br /> EH 23081(12/62010) <br />