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pPp,urN � r. ENVIRO ENTAL HEALTH DOPARTMENT •C4�%FO-R a�P SAN JOAQUIN COUNTY Program Coordinators Donna K.Heran,R.E.H.S. 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 II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: LC. I. Chemicals Hazards Address: -S • _ ElCarcinogens: Contact Pers n: ❑Corrosives: Phone#: 9) dt ❑Dusts: Proposed Date of investigation/inspection: I ❑Explosives: �4Flammables: 4C mi` lie 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: 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: Photo❑Photo ionization Detector ❑Gr;anic 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 ❑Tyvek ❑Confined space entry(explosions): ❑ Respirator: ❑APR ❑SCBA Xeavy equipment(physical injury&trauma resulting from moving A/P Cartridge: uipment): Z Safety vest Q ❑Other(specify): Two-way communication ? V( '�-` ❑Other(specify): 7. Anticipated Biological Hazards: Snakes XInsects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: e.g.,power lines,integrity of dikes,terrain,etc.): 5Q�2 Plan Approved by: Date: L EH 23081 (12/16/2011)