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il0 'C p <br /> EmgRC TMENTAL HEALTH I LPARTMENT <br /> c ~ �� SAN JOAQUIN COUNTY <br /> �/FORS' <br /> Donna K.Heran,RE.H.S. Program 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/chd Jeff Carruesco,R.E.H.S. <br /> Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN' <br /> PART <br /> GENERAL SITE QRMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: �� _' 1. Chemicals Hazards <br /> Address: c L_> <br /> ❑Carcinogens: <br /> Contact Person: <br /> / 7� .- C S� <br /> Q Corrosives: <br /> Phone#: <br /> O ousts: <br /> Proposed Dae of investigation/inspection: - 37- I/ <br /> ❑Explosives: <br /> 2. Description and brief narrative of inspection activity: ❑Flammables: <br /> ❑Inorganic Gases: <br /> ❑New UST installation C1UAR Investigation 0 Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs.- <br /> ID Sampling ❑Boring/Monitoring Well installation <br /> �azardous Waste inspection ❑Other: <br /> ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitorin Equipment <br /> Tank Content: g Eq P ment <br /> (Note:Monitoring instruments must be used for all <br /> Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: /� L / ❑Combustible Gas/Oxygen Meter <br /> t`E 'T / l c S ❑Detector Tubes(specify): <br /> 4. Type of Operation: r: <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 oractivity/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 /> ❑Excavation(falls,trips,slipping,cave-ins): D Flame retardant coveralls I <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hag Protection <br /> ❑Tyvek <br /> i <br /> ❑Confinedce en ❑SCBA <br /> spa try(explosions): ❑Respirator: APR <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: I <br /> equipment): <br /> ®Safety vest <br /> ❑other(specify): <br /> ❑Two-way communication i <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> PART IV <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 b : G� ( / <br /> ofdikes,terrain,etc.): Date: ( f <br /> Plan Approved b : Date: <br /> I <br /> EH 23081 (12/6/2010) <br /> I <br />