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AQu1N e <br /> �4•'��••.oma i <br /> ENVIRONMENTAL HEALTH DLOeARTMENT <br /> .....'.. :P <br /> Donna K.Reran,R.E.H.S. SAN JOAQUIN COUNTYProgram 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 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 <br /> 't�INFORMATION <br /> ," , L EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Nameo e 1, /�/1 Q-�'►�C�C'_. / 1. Chemicals Hazards J -- L <br /> Address: 0/45 S. (_5 1 -bo rRLtr, St. Carcinogens:�SDd'�Ch6 <br /> Contact Person: ❑Corrosives: <br /> Phone#: - � 4 ❑Dusts: <br /> Proposed Date of investigation/inspection: t ❑Explosives: <br /> Cklammables: <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: 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 /> /� /J <br /> [I Detector Tubes(specify): <br /> 4. Type of Operation: C7 Q�/,/ ) _ ❑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 instnunents 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 /> xcavation(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 /> IgHeavy equ ent(ph i�a1 injury&trauma resulting from moving A/P Cartridge: <br /> equipment):\ Zj <br /> �J e� ®Safety vest /o�,,, ,, <br /> C1 Other(specify): )'wo-way communication Ph ��- <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> SnakesInsects *odents ❑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: 2S <br /> e.g.,power lines,integrity of dikes,terrain,etc.): f <br /> Plan Approved by: Date: �1 <br /> EH 23081(5/5/2011) <br />