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pA4try. a , 1 ENVIRONRENTAL HEALTH DEPARTMENT Donna 14 Heron,RE.ft.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.H.H.S. s Ov.Or ehd Jeff Canuesco,R.E.H.S. Web:www JS g/ Linda Turkatte,R.E.H.S. SPIE HEALTH&SAFETY PLAN PART PART H GENERAL SITE INF EVALUATION EVALUATION OF POTENTIAL HAZARDS 7 f� 1. Site Name: Y l�T 16^ 1. Chemicals Hazards Address: / c,_o ❑Carcinogens: Contact Person' FzyC ""X�i�� ❑Corrosives: Phone k: ❑Dusts: Proposed Date of investigation/inspectiow ❑Explosives: ❑Flammables: 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation ❑Other: Hazardous Waste inspection ❑Tiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments most be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other.. ❑Combustible Gas/Oxygen Meter IA l rr( f E]Detector Tubes(specify): 4. Type of Operation: r -r V A ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(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 Flat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots ❑Excavation(falls,nips,slipping,cave-ins): ❑Flame retardant coveralls Handling and Transfer of a Hazardous Substance(Fire,explosions,etc.):, ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator. ❑APR ❑SCBA .F,b Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): ❑Two-way communication ❑ Other(specify): 7. Anticipated Biological Hazards: ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b . Date: �S / e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved y:�z Date: C/ / EH 23081(6/14/2011)