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PqurN .. W ENVIRONMENTAL HEALTH D ARTMENT • c°��Foaa�P SAN JOAQUIN COUNTY program Coordinators Donna K.Heran,R.E.H.S Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. Jeff Carruesco,R.E.H.S. Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1. Chemicals Hazards Address: ❑Carcinogens: Contact Person: a rro ❑Corrosives: Phone#: ❑Dusts: Proposed Date of investigation/inspection: 13—N-11 ❑Explosives: ❑Flammables: 2. Description and brief narrative of inspecl ion activity: ❑Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑TukIPipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑Re xcavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation ❑Other: _—JS4Iazardous Waste inspection ❑Ti ed Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other: ❑Combustible Gas/Oxygen Meter ❑Detector Tubes(specify): 4. Type of Operation: ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any previ us investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Conc s:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD ❑Heat or Cold Stress: OF igh ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots ❑Excavation(falls,trips,slipping,cave ins): ❑Flame retardant coveralls '/M El and Transfer of a Hazardo Substance(fire,explosions,etc.): ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA � Heavy equipment(physical injury& uma resulting from moving �'Cartridge: J equipment): Z Safety vest ❑Other(specify): ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by Date: �i e.g.,power lines,integrity of dikes,terrain,etc.): A' Plan Approved b Date: I l EH 23081(6/14/2011)