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. �G••.oma <br /> r.' <br /> ENVIRC 'MENTAL HEALTH &PARTM[ENT <br /> SAN JOAQUIN COUNTY <br /> Lonna K.Reran,R.E.H.S. SAN <br /> Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART-1 <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: —'–=I)✓*-1.f <br /> ]. Chemicals Hazards <br /> Address: t f� ?.5 <br /> ❑Carcinogens: <br /> Contact Person:_ �.. L) <br /> O Corrosives: <br /> Phone#i:_ -I-)'L,5 7 a -ice <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: / /fa, _ <br /> ❑Explosives: <br /> ❑ <br /> 2. Description and brief narrative of inspection activity: Flammables: <br /> ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> 0 Sampling ❑Boring/Monitoring Well installation Other: <br /> 'D�Iazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: ]. 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: lr_;,S <br /> ❑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 ®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 /> Q Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Oji Iandling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ¢}Confined space entry(explosions): ❑Respirator: <br /> ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): <br /> ®Safety vest <br /> Other(specify): ❑Two-way communication <br /> Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV I <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, / <br /> e.g.,power lines,integrityPlan Prepared by: f <br /> of dikes,terrain,etc.): ., `-�"_ Date: � �� ,• 1 <br /> Plan Approved by: /;PC) Date: <br /> f <br /> EH 23081(12/62010) i <br /> j <br />