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OPOu1N C Z� ENVIRON 1 ENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY �<<F p•R Program Coordinators Donna K.Heran,R.E.H.S. Kase L.Foley,R.E.H.S. Director 600 East Main Street, Stockton, California 95202 Y Y, 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 INFORMATION �� EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1. Chemicals Hazards Address: 2 Af arcinogens: Contact Person: 1WCorrosives: Phone#: 1140):770 -1- ❑Dusts: Proposed Date of investigation/inspection: ❑Explosives: ❑Flammables: 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation Other: �Iazardous Waste inspection E)Tiered Permitting inspection ^^ PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other: ❑Combustible Gas/Oxygen Meter Q,� ❑Detector Tubes(specify): 4. Type of Operation: 4 A!!30 O�- ❑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 previous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Concerns:(✓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,cave-ins): ❑Flame retardant coveralls Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): 'NCfwo-way communicatio0zDXle— ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes '*N�nsects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 1 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: 1� e.g.,power lines,integrity of dikes,terrain,etc.): 1 Plan Approved by: VU� Date: EH 23081 (2/7/2011)