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O.P�u1N• C <br /> W <br /> Z ETSMRON&ENTAL HEALTH IRPARTMENT <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY program Coordinators Director 600 East Main Street, Stockton,California 95202 Kase y L.Foley,RE.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 Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE I 'FORMATI N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: L Chemicals Hazards <br /> Address Carcinogens: a <br /> Contact Persop: ❑Corrosives: <br /> Phone#: (Z0 YJ 2 ❑Dusts: <br /> Proposed Date of investigation/inspection: — 1 Z ❑ Explosives: <br /> ❑Flammables: <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 /> azardous Waste inspection ❑Tiered Permitting inspection <br /> 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 /> 1 n l n nn �' ❑Detector Tubes(specify): <br /> 4. Type of Operation: rl P(A V t/1 D. L r I Y l��-� ❑Photo ionization Detector <br /> 'J c ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO done(see below) <br /> Documented Groundwater contamination: C]YES C1 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: IF(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 /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> A <br /> eavyequipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> uipment): ®Safety vest <br /> El Other(specify): Two-way communicationLl?Z <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards' <br /> �nakes 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: , �Z <br /> e.g.,power lines,integrity of dikes,terrain,etc.): i <br /> Plan Approved by: J Date: I <br /> EH 23081(3/5/2012) <br />