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"Qw1v <br /> vo.�.cod <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> • c��iFoa�:'• SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y y. <br /> 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 /> 1. Site Name: r-D D• 1. Chemicals Hazards <br /> Address: ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: // ..� <br /> VFlammables:L Q _ 6l� O U,LVL_, <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 /> �-lazardous Waste inspection [j Tiered Permitting inspection <br /> �v PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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: ` ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO Ione(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 ED <br /> ❑Heat or Cold Stress: °F(high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> xcavation(falls,trips,slipping,cave-ins): <br /> ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> p Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Kheavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): �L( ox/� E Safety vest <br /> ❑Other(specify): ( Two-way communicationt7 N-Z <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Snakes '�g Insects gRodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b ate: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: `-' Date: G� <br /> EH 23081(5/5/2011) <br />