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PgUtN <br /> r z ENVIRON ENTAL HEALTH D PARTMENT <br /> F12 <br /> ORa.P SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. <br /> Director 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 /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name. 1. Chemicals Hazards <br /> Address: .1-13 42VCazcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: —tt-7 O — O ❑Explosives: <br /> lammables: <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: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> �&azardous Waste inspection F1 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 Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> A � <br /> [I Detector Tubes(specify): <br /> 4. Type of Operation: 1"l c a\rJl ❑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 ED <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> Noise Sources: ®Safety Glasses/Goggles <br /> 'ftOxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ;Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ;9ri-Iandling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> quipment): ®Safety vest RIO <br /> I Other(specify): I<Two-way communication IO <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes Insects �odents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): , _I <br /> Plan Approved by: tM' Date: <br /> EH 23081 (4/7/2010) <br />