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Pqurry z ENVIRON ENTAL HEALTH DPARTMENT C,�iFORa�P Donna K.Heran,RE.H S. SAN JOAQUIN COUNTY Program Coordinators 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,RE.H.S. Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL t"TE RMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Nam1. Chemicals Hazards Address: 9.� `carcinogens: Contact /❑'Corrosives: Phone#: ❑Dusts: Proposed Date of investigation/inspec n: ❑Explosives: ❑Flammables: 2. Description and brief narrative of ins tion activity: ❑ Inorganic Gases: ❑New UST installation ❑U Investigation ❑Metals: ❑Tank Closure in Place ❑T k/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑ R -excavation ❑PCBs: ❑Sampling ❑Bring/Monitoring Well installation ❑Other: Hazardous Waste inspection ❑Ti ed Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Ta nk Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: Ta ik 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 ❑NOIone(see below) Documented Groundwater contaminati C]YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any p ous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Con s:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD ❑Heat or Cold Stress: °F(iigh ambient temp.) ®Hard Hat oise Sources: ®Safety Glasses/Goggles xygen Deficiency: ®Steel toed/shank shoes or boots ❑Excavation(falls,trips,slipping,ca v ins): ❑Flame retardant coveralls Handling and Transfer of a Hazardo Substance(fire,explosions,etc.):. ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA jIeavy equipment(physical injury& rauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): %90wo-way communication 01A—� ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes X'sects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which ould impact Health and Safety, Plan Prepared b Date: e.g.,power lines,integrity of dikes,terra' ,etc.): }� Plan Approved by: Date: V �� EH 23081(5/5/2011)