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ENVIRIDAENTAL HEALTH D ARTMENT �q�1FO.R�`P Donna K. Heran,R.E.H S. SAN JOAQUIN COUNTY Program Coordinators Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. Jeff Carruesco,R.E.H.S. Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL SITE INFOWATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: ' u l S 1. Chemicals Hazards Address: &_ A Carcinogens: Contact Person: M ❑Corrosives: Phone#: -0 gay ❑Dusts: Proposed Date of investigation/inspect on: ( Explosives: Flammables: 2. Description and brief narrative of in tion activity: ❑Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑ ipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑ -excavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation ❑Other: �]Hazardous Waste inspection ❑Tiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Mink Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: T mk Age: operations unless appropriate rationale or restrictions are provided): Other.: ❑Combustible Gas/Oxygen Meter ❑Detector Tubes(specify): 4. Type of Operation: ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any pre tious investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Cot ceras:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ® D ❑Heat or Cold Stress: °F high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots ❑Excavation(falls,trips,slipping,care-ins): ❑Flame retardant coveralls ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA [kpeavy equipment(physical injury trauma resulting from moving A/'Cartridge: equipment): ®Safety vest Other(specify): S ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes Insects ❑Rodents Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL / 8. Narrative(provide all information whic ^could impact Health and Safety, Plan Prepared by: ' ,-�P-42 Date: I it e.g.,power lines,integrity of dikes,tern in,etc.): �Q Plan Approved by: Dat EH 23081(5/18/2011)