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P+RurN. ENVIROT r.� , y s: .a ta::. :< c��iFoaNvP Donna K. Heran, R.E.H.S. Director Laurie A. Cotulla, R.E.H.S. Assistant Director PART GENERAL SITE INFORMATION .'IENTAL HEALTH4f)EPARTMENT SAN JOAQUIN COUNTY 304 East Weber Avenue, Third Floor Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd SITE HEALTH & SAFETY PLAN Program Coordinators Carl Borgman, R.E.H.S. Mike Huggins, R.E.H.S., R.D.I. Kasey L. Foley, R.E.H.S. Margaret Lagorio, R.E.H.S. Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. PART II EVALUATION OF POTENTIAL HAZARDS Site Name: Miracle Mile Dry Cleaning }, E.hemiesls Hazards Address: 82 W Castle ❑ Carcinogens: PERC Contact Person: Yvonne Wilton Phone No: (Click here and typel ❑ Corrosives: [Click here and typel Sweeps Number: [Click here and type] ❑ Dusts: (Click here and type] Proposed Date of investigation/inspection: 12-16-08 ❑ Explosives: (Click here and tvnel 2. Description and brief narrative of inspection activity: ❑ New UST installation.. ❑ UAR Investigation. ❑ Tank Closure in Place.. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ Installation of Borings / Monitoring Wells. ❑ Hazardous waste inspection ❑ Sampling ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: (Click here and typel Tank Capacity:[Click here and typel Tank Content: [Click here and typel Tank Age: [Click here and type] Other: [Click here and typel 4. Type of Operation: Dry Cleaning 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: [Click here and typel 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Heat or Cold Stress:[Click here and typel °F (high ambient temp.) ❑ Noise Sources: (Click here and typel ❑ Oxygen Deficiency: (Click here and typel ❑ Excavation: (falls, trips, slipping, cave-ins): [Click here and type] ❑ Handling and Transfer of a Hazardous Substance: (tire, explosions, etc..): [Click here and typel ❑ Confined space entry: (explosions): [Click here and typel ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): [Click here and type] ❑ Other, specify: [Click here and typel ,Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): [Click here and typel 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (02/19/03) ❑ Flammables: 77:2 ❑ Inorganic Gases: [Click here and typel ❑ Metals: [Click here and typel ❑ Oxidizers: [Click here and Npel_ ❑ PCB's: [Click here and typel PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: Stay away from hazards 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat. ® Safety Glasses/goggles. ® Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: [Clickhere and type] ® Safety vest. ❑ Two-way communication. PART IV - PLAN APPROVAL Plan Prepared by: Garrett Backus Date: 12-16-08 Plan Approved by: Date: