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OPO u'N C <br /> ENVI ONMENTAL HEALTH DEPARTMENT <br /> ;Fo'Ra;P. SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K. Heran,R.E. .S. <br /> Dirc 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 /> Jeff Carruesco,R.E.H.S. <br /> Web: www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:U _ 1. Chemicals Hazards <br /> Address: carcinogens: <br /> Contact Pe n: 1rLZ ❑Corrosives: <br /> Phone 4: �� .3 ❑Dusts: <br /> Proposed Date of investi tion/inspe on: ❑Explosives: <br /> lammables: <br /> 2. Description and brief n five of inspection activity: Inorganic Gases: <br /> ❑New UST installation ❑ AR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑ ank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ Ze-excavation ❑PCBs: <br /> ❑Sampling ❑ 3oring/Monitoring Well installation ❑Other: <br /> )Gazardous Waste insp %tion ❑ 'iered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: ank Capacity: I. 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: t ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ft�v ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil co taminatio : ❑YES ❑NO Y6one(see below) <br /> Documented Groundwatet contamina ion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pr vious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety hysical C %erns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <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 ve-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry( xplosions): ❑Respirator: ❑APR ❑SC13A <br /> *Nmeavy equipm t(physical injury k trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): [ awo-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological H ds: <br /> �]Snakes Insects -Woden s ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(speci ): PLAN APPROVAL <br /> 8. Narrative(provide all infoi mation whi h could impact Health and Safety, Plan Prepared b Date: <br /> e.g.,power lines,integrity f dikes,to ain,etc.): `. <br /> Plan Approved by: V"'' Date: 5 ZY <br /> EH 23081 (4/7/2010) <br />