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4!C(y <br /> agion� <br /> ENVIIZ01h8IENTAL HEALTH DtfARTMENT <br /> SAN JOAQM COUNTY PrgFai,Coordinators <br /> Dona K Haran,RE.H.S. <br /> Director600 East Main Street, Stockton,California 95202 I{asey L.Foley,R.E.H.S.Telephone:(209)468-3420 Fac Robert McClellon,RE.H.S. <br /> (209)468-3433 Jeff Carruesco,R.H.H.S. <br /> Web.www.sjgov.org/ehd Linda Turkatte,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: ML1 <br /> _ 4c(A 11. ,C,,,ehr,emicals Hazards <br /> d <br /> Address: ZOl W _G(A S�cI�-� mLL✓l�-ftlh Caroinogens: <br /> Contact Person 7 ❑Corrosives: <br /> Phone#: (Zene") zacl— Ja Dusts: <br /> Proposed Date of investigaticn inspection: 15 Explosives: <br /> 'aFlan mables: <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: l. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Contant: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> l ❑Detector Tubes(specify): <br /> 4. Type of Operation: x1,17) 40,4,-r ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> ❑Heat or Cold Stress: °F(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,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&tratrma 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 ;Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: M Naidu Date: 3 �� <br /> e.g.,power lines,integrity of dikes,terain,etc.): <br /> Plan Approved by: Date: <br /> EH 23081(5/62011) <br />