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P(;U I/y � • <br /> r Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> '- SAN JOAQUIN COUNTY Program Coordinators <br /> %FOR <br /> Donna K.HeranDirector <br /> R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y y. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web: www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INF RMAT ON EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazard's. n _p <br /> Address: Carcinogens: U.lK`LW C �t f <br /> Contact Person: <br /> C/ u ❑Corrosives: <br /> Phone#: o "l l � —1 Dusts: <br /> Proposed Date of investigation/inspection: `)�7 .o ❑Explosives: �/y <br /> aFlammables: Ob <br /> 2. Description and brief narrative of inspection activity: -d Inorganic Gases:0 XICAPJA <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 /> IpHazardous Waste inspection C3 Tiered Permitting inspection <br /> Ip <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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 /> q� L, p ❑Detector Tubes(specify): <br /> 4. Type of Operation: �°R� I(d �U 6 i Photo ionization Detector <br /> J ❑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 E D <br /> ❑Heat or Cold Stress: 'F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling 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 <br /> A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH 23081(8/6/2010) <br />