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ip ENVIRONMENTAL HEALTH D-LPARTMENT SAN JOAQUI � COUNTY Program Coordinators Donna K. Heran, R.E.H.S. Kase L. Foley, R.E.H.S. Director 600 East Main Street, Stockton, California 95202 y y. 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 INF RMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: ) /� 5� 1. Chemicals Hazards Address: ❑Carcinogens: Contact P - kA. I Warm ❑ Corrosives: Phone #: t— ❑ Dusts: �, Proposed Date of investigation/inspeJctron: ❑ Explosives: ❑ Flammables: 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: 9 )iazardous Waste inspection C] Tiered Permitting inspection r ari I PART III Ml e u `� j� q 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): pp��A I_�",,", 4. Type of Operation: �iinll ((LC I dW�if t�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: 6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (5/9/2011) 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat ® Safety Glasses/Goggles ® Steel toed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR A/P Cartridge: ® Safety vest ❑ Two-way communication ❑ Other (specify): ❑ SCBA PART IV PLAN APPROVAL i Plan Prepared by: Date: Plan Approved by: ` Date: