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ENVIRO#NIENTAL HEALTIMEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna K.Heran,R.E.H.S. <br /> Ra`P Director Program Coordinators <br /> o• <br /> 600 E. Main Street Carl Borgman,R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. Stockton, California 95202 Mike Huggins,R.E.H.S.,R.D.I. <br /> Assistant Director Kasey L.Foley,R.E.H.S. <br /> Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Fax: (209).464-0138 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:GEORGE KISHIDA,INC 1. Chemicals Hazards <br /> Address: 1725 ACKER MAN DR <br /> El Carcinogens: <br /> Contact Person:KELLY KISHIDA Phone No:465-3205 ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection:10/30/07 ❑Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic 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.: 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:Truck Maintenance Facility ❑ Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES F1 NO If monitoring instruments are not used,rationale or activity/area restrictions: <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 ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ® <br /> El Oxygen Deficiency: Hearing protection. <br /> ®Excavation:(falls,trips,slipping,cave-ins): El Tyvek. <br /> ❑ ❑ <br /> El Handling and Transfer of a Hazardous Substance:(fire,explosions, Respirator: El APR SCBA <br /> etc..): A/P cartridge: <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 I1 <br /> 7. Anticipated Biological Hazards: Plan Prepared by: Date: I U 0 <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants 12 <br /> E]Other/Unknown(specify): �2 <br /> Plan Approved by: Date: <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 />