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ENVIR NMENTAL HEALTH DEPARTMENT <br /> C4��FORa�P SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H S. Kase L. Coordinators <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 /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION , y EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: S `f 'U Fi 1. Chemicals Hazards <br /> Address: 1) ( S Carcinogens: LWO*& O i( —tom,0 <br /> Contact Person: ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investiga'on/inspect on: ❑Explosives: <br /> JIFlammables: <br /> 2. Description and brief narra've of inspe Dtion activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑U kR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑T ipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Bering/Monitoring Well installation ❑Other: <br /> Irl azardous Waste insp on El Ti Permitting inspection <br /> Irl <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Ta ik Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Ta ik 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 con ' ation: ❑YES ❑NO C]None(see below) <br /> Documented Groundwater c ntaru ti : ❑YES [I <br /> NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description f any prev ous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety P ical Con s:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ® D <br /> ❑Heat or Cold Stress: °F(ligh ambient temp.) <br /> ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cavins): ElFlame retardant coveralls <br /> C1Handling and Transfer of a H Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> C]Confined space entry(explosions): 14 wA ❑Respirator: ❑APR ❑SCBA <br /> A/P Cartridge: <br /> C1 equipment(physical injury&1 raurna resulting from moving <br /> equipment): <br /> ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological H <br /> ❑Snakes ❑Insects Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL '} <br /> 8. Narrative(provide all informajtion which ould impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of 4ikes,terrai ,etc.): 1777 U <br /> Plan Approved by: Ir V Date: / <br /> EH 23081(5/9/2011) <br />