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w ENVIRON ENTAL HEALTH AARTMENT <br /> Donna K.Heron,R.E.H.S. SAN JOAQUIN COUNTYProgram Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.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 INFORMATION (}�,,, ,, EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: B S �l f ,/,^1z CP41 1//�� 1. Chemicals Hazards <br /> Address: ��-1 I'i - ��c,.n,,.,cyr fi-I wa"7`S^' X"Carcinogens: <br /> Contact Person: L F/1'(�/1VTLJ. / C1 Corrosives: <br /> Phone k: —0&9D I ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑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 /> ]"Hazardous Waste inspection [I Tiered Permitting inspection <br /> JC• 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 /> [I Detector Tubes(specify): <br /> 4. Type of Operation (/ ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: E]Other(specify): <br /> Evidence of leaks/soil contamination: (-IYES ❑ ) <br /> NO &one(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 /> ,,aa,,,,��Excavation(falls,trips,slipping,cave-ins): C]Flame retardant coveralls <br /> t�Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> / ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> >�ieavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest y� <br /> ❑Other(specify): XTwo-way communication r„0 PuL_ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes Insects J<odents E]Poisonous Plants PART IV <br /> ElOther/Unknown(specify):` PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: 6 / <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: � Dale: <br /> EH 23081(9/15/2010) <br />