Laserfiche WebLink
PgUlry <br /> y ENVIRONSENTAL HEALTH D ARTMENT <br /> ••Cq<<FOR�j�P.• <br /> Donna K.Hei an,R.E. .S. SAN JOAQUIN COUNTY Program Coordinators <br /> Dire for 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> JeffCatruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INF RMATI N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazard's'n,,' ,, <br /> Address: .E Carcinogens: W�61 <br /> Contact Person: ❑Corrosives: <br /> Phone#: [I Dusts: <br /> Proposed Date of investig4tion/inspe ion: ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narr ive of inslection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑ JAR Investigation .Metals: M M L <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ e-excavation ❑PCBs: <br /> ❑Sampling 3oring/Monitoring Well installation ❑Other: <br /> Yazardous Waste insp ction ❑Tiered Permitting inspection <br /> PART III <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: ank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contaminatioi ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamina ion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any p vious 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 ND <br /> ❑Heat or Cold Stress: (high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,c ive-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazar ous Substance(fire,explosions,etc.) ®Hearing protection <br /> ❑Tyvek <br /> El Confined space entry xplosions) El Respirator: El APR [I SCBA <br /> El Heavy equipment(physical injury trauma resulting from moving A/P Cartridge: <br /> equipment): i ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological H ards: <br /> ❑Snakes ❑Insects ❑Rode ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all info ation wh ch could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,to Tain,etc.): n t <br /> '']Plan Approved by:TV Date: / l `J <br /> EH 23081(6/14/2012) <br />