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Pp.UI/y H X ENVIRONMENTAL HEALTH D PARTMENT • oq�iFo�ri�P Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. SITE HEALTH & SAFETY PLAN PART I PART II GENERAL SITE INFO ATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1 1. Chemicals Hazards ��"" Address: C5S • -4f Carcinogens: Arl fifref?.Q_.. ll1 �' 1(.dCA D7 Contact Person: /L( i'I t • ) Worrosives: A1408) Z. &'ova H F Phone #: Zo —JS�J ❑ Dusts: Proposed Date of investigation/inspection: 1 ❑ Explosives: 19:Flammables:AGGiN�1 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: ❑ New UST installation ❑ UAR Investigation ❑ Metals: ❑ Tank Closure in Place ❑ Tank/Pipe Repair tg Oxidizers: BJC�.ri ❑ Tank/Pipe Removal ❑ Re -excavation ❑ PCBs: ❑ Sampling ❑ Boring / Monitoring Well installation 00ther: j�A Ae X .d &_A421f4 Hazardous Waste inspection �fiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: I. Monitoring Equipment (Note: Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other: ❑ Combustible Gas/Oxygen Meter �Y ❑ Detector Tubes (specify): 4. Type of Operation:❑Photo ionization Detector ❑ Organic Vapor Analyzer 5. Release History: ❑ Other (specify): Evidence of leaks / soil contamination: ❑ YES ❑ NO )ZINone (see below) Documented Groundwater contamination: ❑ YES ❑ NO If monitoring instruments are not used, rationale or activity/area restrictions: Background and description of any previous investigation or incidence: 6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: xcavation (falls, trips, slipping, cave-ins): Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): >(Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: .Snakes \ Insectskodents ❑ Poisonous Plants ❑ Other/Unknown (specify): Narrative (provide all information which could impact Health and Safety e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (2/7/2011) 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat ® Safety Glasses/Goggles ® Steel toed/shank shoes or hoots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR ❑ SCBA A/P Cartridge: Z Safety vest :ELTwo-way communication f4q V�rxx_ _ ❑ Other (specify): PART IV PLAN APPROVAL / Plan Prepared Date: 2( % Plan Approved by: Date: