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o'qu!ty C -I��l 2. ENVIRONMENTAL HEALTH DEPARTMENT C��iFORa�r Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. Jeff Carruesco,R.E.H.S. Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. SITE HEALTH & SAFETY PLAN PART I PART H GENERAL SITE INFORMATION n EVALUATION OF POTENTIAL HAZARDS 1. Site Name: v��X S 1. Chemicals Hazards Address: ❑Carcinogens: Contact Person: ❑Corrosives: Phone#: ❑Dusts: Proposed Date of investigation/inspection: ❑Explosives: ammables: 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: ❑Sampling ❑Boring/Monitoring Well installation ❑Other: �4;�Hazardous Waste inspection ❑Tiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other: ❑Combustible Gas/Oxygen Meter ❑ Detector Tubes(specify): 4. Type of Operation: 9=411Z 6i 5 ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any previous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots 'Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls andling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection ltgl� ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: 7i e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved by: r)fL Date: EH 23081(4/12/2012)