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O.P4u 1 N••.0 *.M E VIR NENTAL HEALTH DEPARTMENT Donna K.Her n,R.E.H S. SAN JOAQUIN COUNTY Program Coordinators gt�Foa� Dire or 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 INFORM IT ON EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1. Chemicals Hazards Address: ❑Carcinogens: Contact Person: t Corrosives: S-tU Phone#: 0 V ❑Dusts: Proposed Date of investigal on/inspect' n: ( ❑Explosives: 017lammables: 1 1 2. Description and brief narrat ve of inspe tion activity: 'Inorganic Gases: it ❑New UST installation ❑U Investigation J 'Metals: it ❑Tank Closure in Place ❑TE nk/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑R -excavation ❑PCBs: ❑ Sampling ❑Boring/Monitoring Well installation ❑Other: �azardous Waste inspection E]Ti red Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tk Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: -T;k 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 con ination: ❑YES ❑NO ❑None(see below) Documented Groundwater cntaminatio : E]YES F1NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description f any prev us investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Ph rsical Conc ms:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD ❑Heat or Cold Stress: °F(I iigh ambient temp.) E Hard Hat ❑Noise Sources: E Safety Glasses/Goggles ❑Oxygen Deficiency: E Steel toed/shank shoes or boots ❑Excavation(falls,trips,sl ping,cave-ins): F]Flame retardant coveralls ❑Handling and Transfer of Hazardous Substance(fire,explosions,etc.): E Hearing protection ❑Tyvek ❑Confined space entry(exp osions): ❑Respirator: ❑APR ❑SCBA ❑Heavy equipment(physici I injury&t auma resulting from moving A/P Cartridge: equipment): E Safety vest ❑Other(specify): ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazar s: ❑Snakes ❑Insects Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL q 8. Narrative(provide all informa ion which ould impact Health and Safety, Plan Prepared by: CD-Lm' ._ Date: e.g.,power lines,integrity of 'kes,terrai ,etc.): Plan Approved by: RU Date: EH 23081 (12/30/2011)