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Phu 1,N. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY Program Coori inalors <br /> '�iFo'R`� Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 1868 E. Hazelton Ave., Stockton, California 95205 Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> Rodney Estrada,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,R.E.H.S. <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 5Q 1. Chemicals Hazards <br /> Address: Y ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: — ❑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 ❑TanWPipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation Other: 7 <br /> AFlazardous Waste inspection ❑Tiered Permitting inspection <br /> ❑Hazardous Materials Business Plan PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other: ❑Detector Tubes(specify): <br /> ❑Photo ionization Detector <br /> 4. Type of Operation: ®, ,1., Z3�l� � ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: None(see below) <br /> Evidence of leaks/soil contamination: El YES [I NO If moonit'o'r'ing instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C <br /> 6. Potential Health&Safety Physical Concems:(check all that apply& ❑Hard Hat <br /> describe) ❑Safety Glasses/Goggles <br /> ❑Heat or Cold Stress: °F(high ambient temp.) >�teel toed/shank shoes or boots <br /> ❑Noise Sources: ❑Flame retardant coveralls <br /> ❑Oxygen Deficiency: ❑Hearing protection <br /> excavation(falls,trips,slipping,cave-ins): ❑Tyvek <br /> dandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. El Respirator: F-1APRElSCBA <br /> / A/P Cartridge: <br /> ❑Confined space entry(explosions): ❑Safety vest <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication <br /> equipment): ❑Others eci <br /> (P fY): <br /> ❑Other(specify): <br /> PART IV <br /> 7. Anticipated Biological Hazards: PLAN APPROVAL <br /> ❑Snakes -sects ❑Rodents ❑Poisonous Plants ` <br /> ❑Other/Unknown(specify): Plan Prepared n Date. <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date:"1 v <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> EH 23081(4/11/2013) <br />