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pgU1N ENVIROft4ENTAL HEALTH INPARTMENT • FbF• SAN JOAQUIN COUNTY Program Coordinators Donna K. Heran, R.E.H.S. 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 INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1 1. Chemicals Hazards " f j Address: C:5S • ` Carcinogens: M ifYyu—, 071 6CdCti D7� Contact Person: MGUh9 • , Corrosives: Ala off '& 20 %r Phone #i: Zo —'JS ❑ Dusts: Proposed Date of investigation/inspection: t (I Explosives: C&Flammables:00fa i _1U ) 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: ❑ New UST installation ❑ UAR Investigation ❑ Metals: ❑ Tank Closure in Place ❑ Tank/Pipe Repair Oxidizers: �Cbige� ❑ Tank/Pipe Removal ❑ Re -excavation ❑ PCBs: ❑ Sampling ❑ Boring / Monitoring Well installationOther: Hazardous Waste inspection riered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: l . 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 ❑ 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 one (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: 2. Personal Protective Equipment 6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) Level of Protection: ❑ A ❑ B ❑ C ® D ❑ Heat or Cold Stress: °F (high ambient temp.) ® Hard Hat ❑ Noise Sources: ® Safety Glasses/Goggles ❑ Oxygen Deficiency: ® Steel toed/shank shoes or boots Hxcavation (falls, trips, slipping, cave-ins): C] Flame retardant coveralls andling and Transfer of a Hazardous Substance (fire, explosions, etc.): El Hearing protection ❑ Tyvek ❑ Confined space entry (explosions): ❑ Respirator: ❑ APR ❑ SCBA >Heavy equipment (physical injury & trauma resulting from moving A/P Cartridge: equipment): ® Safety vest ❑ Other (specify): MTwo-way communication f*1 O'/-_2— ❑ Other (specify): 7. Anticipated Biological Hazards: I!T'Snakes N�' Insects R'Rodents ❑ Poisonous Plants PART IV ❑ Other/Unknown (specify): PLAN APPROVAL 8. Narrative (provide all information which could impact Health and Safety, Plan Prepared Date: e.g., power lines, integrity of dikes, terrain, etc.): �j Plan Approved by: Date: Y EH 23081 (2/7/2011)