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Pqurry z EN'VIR MIENTAL HEALTH AARTMENT • coRN`' SAN JOAQUIN COUNTY Program Coordinators Donna K.Heran,R.E. .S. Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. Telephone:(209)468-3420 Fax: (209)464-0138 Robert McClellon,R.E.H.S. J Web: www.sjgov.org/ehd effCarruesco,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL SITE FORM TION ^ ,�_ UA/ EVALUATION OF POTENTIAL HAZARDS 1. Site Name: /►,(�(!`, 1. Chemicals Hazards Address: �,�S��•• 'dCarcinogens: Contact Person: L 4 P #: Corrosives: Proposed Date of investig�tion/inspec ion: hon I I sts: Explosives: 2. Description and brief narrative of inspection activity: ❑Flammables: ❑New UST installation ❑IJAR Investigation ❑Inorganic Gases: ❑Tank Closure in Place ❑ ank/Pipe Repair ❑Metals: ❑Tank/Pipe Removal ❑ e-excavation ❑Oxidizers: ❑Installation of Borings Monitorin Wells ❑PCBs: Hazardous waste inspection ❑ ampling Tiered Permitting inspection � PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank No.: Capacity: operations unless appropriate rationale or restrictions are provided): Tank Content: 7 ank Age: ❑Combustible Gas/Oxygen Meter Other. ❑Detector Tubes(specify): ❑Photo ionization Detector 4. Type of Operation: ❑Organic Vapor Analyzer ❑Other(specify): 5. Release History: ❑None(see below) Evidence of leaks/soil cor tamination ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Documented Groundwater contamination: ❑YES ❑NO Background and descriptio of any previous investigation or incidence: 2. Personal Protective Equipment Level of Protection: ❑A ❑B ❑C ®D 6. Potential Health&Safety Physical Co ceras:(✓all that apply&describe) ®Hard Hat Heat or Cold Stress (high ambient temp.) ®Safety Glasses/Goggles Noise Sources: ®Steel toed/shank shoes or boots ❑Oxygen Deficiency: ❑Flame retardant coveralls ❑Excavation:(falls,trips slipping,cave-ins): ®Hearing protection ❑Handling and Transfer f a Hazardous Substance:(fire,explosions, ❑Tyvek etc.): ❑Respirator: ❑APR ❑SCBA ❑Confined space entry(e plosions): A/P cartridge: eavy equipment(phys cal injury trauma resulting from moving ®Safety vest equipment): ❑Other(specify): Two-way communication ❑Other(specify): 7. ticipated colo rcal H d . Snakes Insects Roden ❑Poisonous Plants PART IV-PLAIN APPRO AL ❑Other/Unknown(specif): Plan Prepared by: Date: 8. Narrative(provide all information whi(h could impact Health and Safety, /�►. e.g.,power lines,integrity of dikes,ten ain,etc.) Plan Approved by: Date: EH 23081(3/9/2010)