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PQUIN <br /> ?� ENVIRONMENTAL HEALTH DEPARTMENT <br /> • cq�fFoa�P• SAN JOAQUIN COUNTY 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 MalesMcCleo,R.E.H.S.S. <br /> Jeff Carruesco,RE.H.S. <br /> Web:www.sljgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: - Carcinogens: l �� <br /> Contact Pers : ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: l l ❑Explosives: <br /> ;5tFlammables• p ry / O_ 4Q&'Z nL <br /> 2. Description and brief narrative of inspection activity: ElInorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair NkOxidizers: f�K ldal.Il <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ElSampling ElBoring/Monitoring Well installation C1Other: <br /> ,RHazardous Waste inspection ❑Tiered Permitting inspection <br /> Hazardous <br /> 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: ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO kkone(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:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(Ph sical inJm'Y&trauma resulting from moving A/P Cartridge: <br /> equipment): Safety vest / �,� <br /> ❑Other(specify): wo-way communication Phl r�-�. <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazard <br /> Snakes �rrsects 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 by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: r I <br /> EH 23081(3/5/2012) <br />