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=zgRgt�!ry1_.cqs <br /> ENVIRONMENTAL HEALTH DrA'ARTMENT <br /> SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Hersh,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Kaley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Wov.or ehd JeffCarruesco,RE.H.S. <br /> eb:www.s <br /> JS Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION / '�t EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: )(iM (n W o 1112—z 1. Chemicals Hazards Oil Address: OSS / f2 A.f _ �Caroinogens-��/ 17D j <br /> Contact Person' 11221aaZI ❑Corrosives: <br /> Phone#: f16 ❑Dusts: <br /> Proposed Date of investigationlinspection: ❑Explosives: <br /> �(Flammablcs- Wp-np <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 Wxidizers:_(IA j <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: 1. Monitoring Equipment(Note:Monitoring immunients 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: 1Y0.1�0 p J� dC)��1�0'S_71�`�� ❑Photo ionization Detector <br /> �r ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NOone(see below) <br /> Documented Groundwater contamination: ElYES ❑NO If nitoring 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 OD <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 /> cavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> vndling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: El APR ❑SCBA <br /> rp��,s eavy equipment(physical injury&trauma resulting from movimg A/P Cartridge: <br /> / equipment): yy®��((Safety vest [���,,, <br /> ❑Other(specify): pD Two-way communicationY r Ltz r( — <br /> ,❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> )-0k <br /> I7"ts Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL 7/ <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V� Date: c). �, tZ.— <br /> EH 23081(3/52012) <br />