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epc#�;.co <br /> ENVIRC.MENTAL HEALTH IMPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Program Coordinators <br /> Donna K xer to R E.xs. 600 East Main Street Stock[ California 95202 Y Foley,R.E.H.S. <br /> Ong Kase L. <br /> Director Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Jeff Cam esco,R.E.H.S. <br /> Web.,WWw.Sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> GENERAL SITE INFORMATION /I EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Nmne: �N-� 1. Chemicals Hazards <br /> Address: �g,0 s� /tel fie,l rip (t! s ❑Carcinogens: <br /> Contact Person: <br /> ❑Corrosives: <br /> Phme#: ❑Dusts: <br /> Proposed Date of investigation/inspection: Z— ZS— /1 ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and briefnsnative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair <br /> ❑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 unless appropriate rationale or restrictions are provided): <br /> Other. ❑Combustible Gas/Oxygen Meter <br /> I1t ❑Detector Tubes(specify): <br /> 4. TypeofOperation: /� rC�=,i � ��` ❑Photo ionization Detector <br /> ❑Organic Vapor Amlyzer <br /> 5. Release History: ❑Otho(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. Persons]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,trips,slipping,cavaim): ❑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 /> ❑Heavy equipment(physical injury&trauma resulting from moving AT Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑hisects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> LL <br /> 8. Ng.,Poe(provide all information ofdtim which could impart Health and Safety, Plan Prepared Z 'lif <br /> e.g.,power lines,integrity ofdikes,terrain,etc.): Date: /1 <br /> ^ �Plan Approved by: V Date: <br /> EH 23081 (12/62010) <br />