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oPqugY•c <br /> ENVIRONMENTAL HEALTH DtkARTMENT <br /> a: a <br /> C4�/FORa�P SAN JOAQUIN COUNTY <br /> Donna K. program Coordinators <br /> Director <br /> r 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 <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: ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: 3 � 2 ❑Dusts: <br /> Proposed Date of investigationhnspection: V,[o O xplosives: NGi�iY?, n 11 <br /> lammables: <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 /> �� <br /> F-1DetectorTubes(specify): <br /> 4. Type of Operation:� Xil'L ❑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 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 OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) E Hard Hat <br /> IOoise Sources: E Safety Glasses/Goggles <br /> N <br /> [I Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> ElExcavation(falls,trips,slipping,cave-ins): El Flame retardant coveralls <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.):. E Hearing protection <br /> PI <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): Two-way communication cob <br /> Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes X <br /> 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 b Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): 11 <br /> Plan Approved by: y A Date: L4 ��`ye <br /> '23081(4/7/2010) <br />