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00.4.V1N. C <br /> ENVIRON ENTAL HEALTH D PARTMENT <br /> SAN JOAQUIN COUNTY <br /> Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Fole R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 Y y <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert Mruesc ,R.E.H.S.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:& 11 111 P C Yet° I. Chemicals Hazards <br /> Address: �Jl D S' Q S<S07'Z/� tom_ carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: 4 12 Dusts: <br /> Proposed Date of investigation/inspection: O ❑Explosives: <br /> UFlammables' gR0 <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair OCIers: <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 instruments 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: �rn��i El Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: El Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring 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:(v/all <br /> Hat <br /> all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> El Heat or Cold Stress: °F(high ambient temp.) <br /> ® <br /> Noise Sources: f_ l!q - )ft 9A!!21— ®Safety Glasses/Goggles <br /> ®Steel toed/shank shoes or boots <br /> [I Oxygen Deficiency: <br /> Flame retardant coveralls <br /> Excavation(falls,trips,slipping,cave-ins): coma � ❑ <br /> 4J Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> 19fHeavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): k ?Two-way communication f Oma <br /> /❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Snakes krInsects Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL �/ <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b . Date: e %10 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ,,11 <br /> Plan Approved by: l A Date: 3 �D <br /> EH 23081(4/7/2010) <br />