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obRurtr C .I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Donna K.Henan,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 1868 E. Hazelton Ave., Stockton,California 95205 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sigov.org/ehd Jeff Carruesco,R.E.H.S. <br /> Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: KingsdOWn Inc. 1. Chemicals Hazards <br /> Address: 1631 Industrial Dr., Stockton ❑Carcinogens: <br /> Contact Person: Matthew Lewis ❑Corrosives: <br /> Phone#: 209-234-1436 ❑Duxts <br /> Proposed Date of investigationlinspection:D( 19, 2O1 Z ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑OAR 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: Adhesive. <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> M Hazardous Materials Business Plan PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/oxygen Meter <br /> ❑Detector Tubes(specity): <br /> 4. Type of operation: Mattress Manufacturer ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5, Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO M 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: I will not be handling or opening any hazardous material <br /> storage containers. <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& Level of Protection: ❑A ❑B ❑C ❑D <br /> describe) ❑Hard Hat <br /> ❑Heat or Cold Stress: -F(high ambient temp.) ❑Safety Glasses/Goggles <br /> ❑Noise Sources: M Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ❑Tyvek <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving M Safety vest <br /> equipment): <br /> ❑Two-way communication <br /> ❑Other(specify): ❑Other(specify): <br /> 7, Anticipated Biological Hazards: PART IV <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> plan Prepared by: Robert Lopez Date: 12t19/2012 <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrityof dikes,terrain,etc. : (2 <br /> ) Plan Approved by: U(2 Date:aZO Iti <br /> EH 23081(8/212012) <br />