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ENVIRON MENTAL HEALTH DE PARTMENT 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: L / ❑Carcinogens: Contact Person: hiJ 44 �orrosives: Phone#: , '','i .�]Dusts:?fd Proposed Date of investigation/insp tion: i f1 ❑Explosives: _[3'nammables: t_ GiD t, 2. Description and brief narrative of in tion activity: ❑Inorganic Gases: ❑New UST installation UAR Investigation ,[Metals:'W ..L'�g ❑Tank Closure in Place C3 Tank/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation ❑Other: azardous Waste inspection E]Tiered Permitting inspection C 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 contaminatio : ❑YES ❑NO ❑None(see below) Documented Groundwater contamin tion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any p evious investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical C nems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D ❑Heat or Cold Stress: F(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots ❑Excavation(falls,trips,slipping, ve-ins): ❑Flame retardant coveralls ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection ❑Tyvek ❑Confined space entry(explosions) ❑Respirator: ❑APR ❑SCBA ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes ❑Insects ❑Rodens ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information whi ch could impact Health and Safety, Plan Prepared by: Date: e.g.,power lines,integrity of dikes,tei rain,etc.): \� Plan Approved by: 1 U �� Date:4 EH 23081(5/9/2011)