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PgUIN <br /> ENVIRON ENTAL HEALTH D ARTMENT <br /> SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Heran,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 Kase Y L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> JeffCarruesco,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 II <br /> GENERAL SITE NFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: 1. Chemicals Hazards <br /> Address: p Carcinogens: oil D�1� <br /> Contact Person: ❑Corrosives: <br /> Phone#: O 2' �2 2 ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: J <br /> �7ammables: l,a X ,AGA 'O Q/J <br /> 2. Description and brief narrative of inspection activity: E] Inorganic Gases: �f <br /> ❑New UST installation [I UAR Investigation ❑l Metals: <br /> E]Tank Closure in Place ElTank/Pipe Repair 150xidizers:N lA ,1 / <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: A I / <br /> E]Sampling ❑ A�Q K1Boring/Monitoring Well installation Other: ,C11. M p i)mYILG <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:Tl /fllAA\r 1 �VIzKM` �tS¢' (t�UT1(.Q ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO None(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 ED <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): <br /> ❑ Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): U�rwo-way communication pr(,v► l X_ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes Insects XRdents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepar Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: ✓ Date: <br /> EH 23081(5/5/2011) <br />