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'OPO. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> •.^,��FOR a`P,� SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Fole 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 Mruesc ,R.E.H.S.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 INFORMAT1,0N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: & 1. Chemicals Hazards <br /> Address: WA OA )2Carcinogens: F�m , <br /> Contact Person: al Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> Flammables:�<� 246& <br /> f F1 � <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 /> `Hazardous Waste inspection ❑Tiered Permitting inspection <br /> I" 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: +0 AA ❑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,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 /> ❑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 ❑Insects ❑Rodents ❑Poisonous Plants PART 1 V <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: f=—, Date:1 , <br /> e.g.,power lines,integrity of dikes,terrain.etc.): <br /> Plan Approved by: Date: <br /> 1[11 23081 (12/30/2011) <br />