Laserfiche WebLink
aqu 1!Y <br /> �o. .eQc <br /> H ENVIRON MENTAL HEALTH DEPARTMENT <br /> o4;i o a�P b r <br /> Donna K.Henan,R.E.H.S. SAN JOAQUIN COUNTY Pro rrrrr 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 /> Teff Carruesco,R.E.H.S. <br /> Web; www.sjgov,orglehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMAT ON EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: I. Chemicals Hazards <br /> Address: V41 19— InA. <br /> ❑Carcinogens: <br /> r <br /> Contact Person: ❑Corrosive <br /> Phone tl: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> ❑Flammablcs: ` <br /> 2. Description and brief narrative of inspection activity: ❑In ani G6aUs: C�(}z <br /> El UST installation ❑'UAR Investigation ❑m <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> NPazardous Waste inspection EJ Tiered Permitting inspection``--'' 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(specify): <br /> 4. Type of Operation: Wk;RA t} ❑Photo ionization Detector <br /> �. ❑Organic Vapor Analyzer <br /> S. 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.) <br /> Wafety <br /> d Hat <br /> El Noise Sources: Glasses/Goggles <br /> ElOxygen Deficiency: l 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 /> qTyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from movingP Cartridge: <br /> equipment): Lafety 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: Date: in oz- L2 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): � <br /> HApproved by: U l�j Date: 113 <br /> EH 23081(6/14/2012) <br />