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PQuIN <br /> ENVIRON*, ENTAL HEALTH DOWARTMENT <br /> -' <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY <br /> C4�IFORa`P Program 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 /> 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: 1. Chemicals Hazards <br /> Address: W warcinogens:pweo Orc�. <br /> Contact Person- I- ❑Corrosives: <br /> Phone#: '7 ez— ❑Dusts: <br /> Proposed Date of investigation/inspection: /a/60 — ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation 0:�4etals: 4 I,/e4- <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair El Oxidizer s: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> 0$azardous Waste inspection El Tiered Permitting inspection <br /> // 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: y r ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: \❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO Z 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 /> ✓all that apply&1 describe Level of Protection: [IA El El ED <br /> 6. Potential Health&Safety Physical Concerns:( ) <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 /> El Excavation(falls,trips,slipping,cave-ins): F1 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 y�',, ,,,A,, <br /> ❑Other(specify): Two-way communication P�'+cJ — <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑SnakesInsects E]Rodents ElPoisonous Plants PART IV <br /> ❑Other/UAlkmnwn(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: Z <br /> e.g.,power lines,integrity of dikes,terrain,etc.): r I <br /> Plan Approved by: � Date: O l� I 2 <br /> EH 23081(3/5/2012) <br />