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0 a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:St.Johns Episcopal Church 1. Chemicals Hazards <br /> Address: 135 E.Miner Ave.,Stockton ®Carcinogens:unknown fuels <br /> Contact Person:Marty Thorpe Phone No:329-5481_ ❑Corrosives: <br /> Sweeps Number ❑Dusts: <br /> Proposed Date of investigationhnspection:January 17,2008 ❑Explosives: <br /> ®Flammablm:unknown fuels <br /> 2. Description and brief narrative of inspection activity: ❑hunganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ®Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ❑Hazardous waste inspection ❑ Sampling PART III <br /> ❑Tiered Permitting inspection <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.:1 Tank Capacity: 1000 gallon I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content:unknown Tank Age:unlmown operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> Other: <br /> ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 4. Type of Operation:Restaurant <br /> ❑Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> 5. Release History: <br /> If monitoring instruments me not used,rationale or activity/area restrictions: <br /> Evidence of leaks/soil contamination: ❑YES ®NO <br /> Documented Groundwater contamination: []YES ®NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C 013 <br /> ® Hard Hat. <br /> 6. Potential Health and Safety <br /> ®Safety Glasses/goggles. <br /> Physical Concerns:(check all that apply&describe) <br /> ®Steel toed/shank shoes or boots. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) <br /> ❑Flame retardant coveralls. <br /> ❑Noise Sources: <br /> ®Hearing protection. <br /> ❑Oxygen Deficiency: ❑Tyvek. <br /> ®Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Respirator: [I APR ❑SCBA <br /> ®Handling and Transfer of a Hazardous Substance:(fire,explosions, A/P cartridge: <br /> etc..): <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> ®Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by:Ray von Flue Date: 1/17/08 <br /> ❑Snakes ❑ Insects ❑Rodents ❑Poisonous Plants 1 // �� (� <br /> ❑Other/Unknown(specify): Plan Approved by: ✓1 1Aw.X�n 3.V Date: Z <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />