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PQUIry <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> c;c;FORS;'. SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K. i rectoran,R�E.x.s. 600 East Main Street Stockton, California 95202 y y,R.E.H.S. <br /> Director Kase L. Foley, <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 INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards r <br /> Address: Carcinogens: <br /> Contact Person: r ❑Corrosives: <br /> Phone#: [;VDusts: <br /> Proposed Date of investigation/' pection Explosives: <br /> ®Flammables: <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 /> Hazardous Waste inspection 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: G ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamina'on: El YES F1 NO E]None(see below) <br /> Documented Groundwater conta ation: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of anprevious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safi Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A El ❑C ®D <br /> El Heat or Cold Stress1 °F(high ambient temp.) ®Hard Hat <br /> C3 Noise Sources: ®Safety Glasses/Goggles <br /> [I Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Flame retardant coveralls <br /> E]Excavation(falls,trilps,slipping cave-ins): <br /> ❑ <br /> ❑Handling and Transfer of a Haz rdous Substance(fire,explosions,etc.): M Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ED Respirator: E)APR E)SCBA <br /> ❑Heavy equipment(physical injufS&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑ Insec ❑Rod is ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(sp ify): IPLAN APPROVAL <br /> Q <br /> 8. Narrative(provide all information hich could impact Health and Safety, Plan Prepared by: Date: Jag <br /> e.g.,power lines,integrity of dikes, errain,etc.): <br /> Plan Approved by: Q Date: <br /> EH 23081 (8/6/2010) <br />