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)q Rqu1N <br /> ENVIRONI ENTAL HEALTH DAARTMENT <br /> Donna K.Heron,RE.H.S. SAN JOAQUIN COUNTY Nogram Coordinators Director 600 East Main Street, Stockton, California 95202 Kase Y L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.H.S. <br /> JeffCarruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SUE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION <br /> TION _� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: //�Q CI f4 c T I"(G�-YlO/ I. Chemicals Hazards <br /> Address: 00A 9' %ocaminogens: I S <br /> Contact Persoo�n� 01d C2 d [ C'ormsives:r [�UYIL QC'/QC/ rok we Z-f <br /> Phone#: (,[� b3 0.37 ❑Dusts: <br /> Proposed Date of investigation/inspection: 77a ,❑.,/Explosives: <br /> trrlammables:,41,49tlgl �4G �, pan. <br /> 2. Description and brief narrative of inspection activity: Norganic Gases:�� �KC.L�Z.Qi <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizerst=t'UZ ZM <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> 777��� 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:f T//Q.r/� �C(C ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO Gone(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 go <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,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 /> eqHeavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> uipment): ®Safety vest <br /> ❑other(specify): l'fwo-waycommunication -Pk Olf-. <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> )rUnakes ec <br /> Insts'�A Rodents ❑Poisonous Plants PART IV <br /> EJOther/Unlmt o_wn(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date:1� <br /> e.g.,power lines,integrity of dikes,termin,etc.): <br /> Plan Approved by: n U Date: <br /> EH 23081(2/7/2011) <br />