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P4UlN. <br /> r. z ENVIRONMENTAL HEALTH DEPARTMENT <br /> • C9��F�.R;;;°' SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Henan,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Kase Y L.Foley,RE.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: OCarcinogens: IS Ol y� <br /> Contact Perso/nn�: PTCorrosives: GIS <br /> Phone#: "l - ❑Dusts: A O <br /> Proposed Date of investigation/inspection: - lyzol ❑Explosives: v� �" <br /> Flammables:: Qe( e <br /> 2. Description and brief narrative of inspection activity: Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: l7Y <br /> ❑Sampling ❑Boring/Monitoring Well installation Other: S ,S <br /> HazardousWasteinspection ❑TieredPermittinginspection YICL({�Iofi1GZ <br /> PART III Z'b� l h o o( �^a 21 rte-�b►uc� <br /> -tom.eklrlct,rl aatnn.,� , <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. 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: (t L ❑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 OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> Voise Sources: ®Safety Glasses/Goggles <br /> ®Steel toed/shank shoes or boots <br /> El Oxygen Deficiency: <br /> Flame retardant coveralls <br /> Excavation(falls,trips,slipping,cave-ins): ❑ <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> �eavy equipment(physical injury&trauma resulting from moving �'Cartridge: <br /> uipment): ®Safety vest ], <br /> ❑Other(specify): Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes sects &odents ❑Poisonous Plants PART IV <br /> ❑Other/Urnlmown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b):- j — Date: �� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): r f <br /> Plan Approved by: L Date: `U <br /> EH 23081(8/11/2011) <br />