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Pqul(y <br /> N ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> c�FORe� <br /> Donna K.Heran,R.E.H.S. Program Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Robert McClellon, R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,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: 1. Chemicals Hazards <br /> Address: ( � �/1) �, sk- carcinogens: U1A4iW, of V -t'f to Fu P,L <br /> Contact Persom, )0 V1 ❑Corrosives: <br /> Phone#: !,b C4 ria ❑Dusts: <br /> Proposed Date of investigation/inspection: (A 011 ❑Explosives: <br /> ❑Flammables: <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 /> 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: VY'.l3L. Qac, f f�Cd Photo ionization Detector <br /> 7 ❑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&SafeV Physical Concems:(✓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 /> ❑ Flame retardant coveralls <br /> Excavation(falls,trips,slipping,cave-ins): <br /> ❑ <br /> ❑ Hearing protection <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): <br /> ® <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR El SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving <br /> 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 IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH 23081 (8/6/2010) <br />