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W. <br /> ENVIRO 1 ENTAL HEALTH D*ARTMENT <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY 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 /> Jeff Catruesco,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: CeU -17 �3'0 [= 1. Chemicals Hazards <br /> Address: /D-7 Z�eyy )0k z JGd Carcinogens: LL�6Uk,(?l 1 <br /> Contact Person: ! Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: 1-7 11 ❑Explosives: <br /> 'R Flammables: �il7l]O hT` Sfn <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 t Other: P1 t ?.r <br /> azardous Waste inspection ❑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: a ,yShop ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: jer(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO e(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If onto 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.): O Tag protection <br /> Y" <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> � <br /> 4-Ieavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): Two-way communication -f hVy C_ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes pl nsects C]Rodents E]Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PIAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, plan Prepared Date: f r <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> ✓ <br /> Plan Approved by: Date: <br /> EH 23081(8/11/2011) <br />