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raq.4A�.PO.e <br /> ENVIRON ENTAL HEALTH DEPARTMENT <br /> Donna K.Haran,RE.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 600 East Main Street, Stockton,California 95202 xaaey L.Foley,R.E.Hs. <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 Linda Turkatte,R.B.H.S. <br /> SUE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATIONlyl EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: — ('IVI.I V)a '//�Eve. ll I C 1. .Cr�hremicals Hazards �n����,1.� <br /> Address: /n1 tat Carcinogens:fY�0r I6VT � <br /> Contact Pen. k 2 J, ❑Corrosives: <br /> Phone#: l ❑Dusts: <br /> Proposed Date of investigationlinspection: ) ❑Explosives: <br /> KFlammables: <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 /> azanlous 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 /> (�r,� n^ ,, <br /> C]Detector Tubes(specify): <br /> 4. Type of operation: 0� � V rdzw ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO `tone(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: E Safety Glasses/Goggles <br /> ❑oxygen Deficiency: <br /> ®Steel toed/shank shoes or boots <br /> Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): Safety vest <br /> El Other(specify); Two-way co <br /> mmunicaticnp� <br /> ❑Other(specify): <br /> T Anticipated Biological Hazards: <br /> Snakes Insects NiZkodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(speciyf): PLAN APPROVAL /n <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b Date: w l <br /> yk <br /> e.g.,power lines,integrity of dikes,terrain,etc.): / <br /> Plan Approved by: Date: l <br /> EH 23081(5/5/2011) <br />