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PgUrN <br /> N: :t <br /> ENVIRON MENTAL HEALTH DAARTIVIENT <br /> r <br /> /pDonna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY <br /> C4CORa�P Program Coordinators <br /> Kase L.Fol R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y Foley, <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McCiellon,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 H <br /> GENERAL SITE INFO ATION / G" EVALUATION OF POTENTIAL HAZARDS <br /> �L <br /> 1. Site Name- /o7-l7/a rawl eiy)7 Q�� 1. Chemicals Hazards <br /> Address:,-3/o 5tICarcinogens: - <br /> D <br /> Contact Person: O 42 /�fn�hCorrosives: <br /> Phone#: LO _6_674541 ❑Dusts: <br /> Proposed Date of investigation/inspection: 3 ❑Explosives: <br /> 9Vlamrnables:,*AAL&0 fl. <br /> 2. Description and brief narrative of inspection activity: t_J Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizers: h <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: ,,`,, <br /> El Sampling ❑Boring/Monitoring Well installation Other: �Y 4b2 <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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NOS one(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 ®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 /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.):_ ®Hearing protection <br /> // ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> gHea-Y equipment(physical injury Y&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): R—two-way communication Fkw nL. <br /> ❑Other(specify): <br /> 7. Anticipated B'ologrcal Hazards: <br /> Xsnakes $Zectsodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH 23081(3/5/2012) <br />