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aqulN <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> •Cq�iFORa•' SAN JOAQUIN COUNTY Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Program CoCo R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 Y Y <br /> Telephone: (209)468-3420 Fax.(209) 464-0138 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO TION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: ru 1. Chemicals Hazards <br /> Address: <br /> ❑Carcinogens: (14 Il <br /> Contact P26'6N', <br /> n: ' e#: ❑Corrosives: <br /> Proposed e o ', igation/mspection: ❑Dusts: <br /> ❑Explosives: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Flammables: <br /> ❑New UST installation ❑UAR Investigation ❑ Inorganic Gases: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Metals: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑Oxidizers: <br /> ❑Installation of Borings/Monitoring Wells ❑PCBs: <br /> Hazardous waste inspection ❑ Sampling <br /> n Tiered Permitting inspection PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 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: <br /> ❑Combustible Gas/Oxygen Meter <br /> Other: <br /> ❑Detector Tubes(specify): <br /> �� El Photo ionization Detector <br /> 4. Type of Operation: {�Q ti On �JTTx (lam ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: <br /> ❑None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring 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 OD <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Hat <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek <br /> etc.): <br /> ❑Respirator: E]APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): <br /> ❑Other(specify). ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes El Insects ❑Rodents ❑Poisonous Plants PART IV-PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> Plan Prepared by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, r <br /> e.g.,power lines,integrity of dikes,terrain,etc.) Plan Approved by , Date: Lf <br /> EH 23081(3/9/2010) <br />