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EN-viw ,MENTAL HEALTHMPARTMENT <br /> c� SAN JOAQUIN COUNTY <br /> �/koaa <br /> Donna K.Heran,RE.H.S. Program Coordinators <br /> Direclor 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> Linda Turkatte,RE.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> —P-A T-J AR <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: !7v�y—�rX I�� ,rte 1. Chemicals Hazards <br /> Address:_ �-f�2 != r' �.x primo <br /> Carcinogens- <br /> Contact Person: <br /> Cotmsives: :7,�,�J���c / � /2� <br /> Phone 4: <br /> ``,, D Dusts: / <br /> Proposed Date of investigation/inspection: `i (�–/I <br /> ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> O Sampling ❑Boring/Monitoring Well installation <br /> ❑Other: <br /> -- -lazardous Waste inspection-0Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 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 /> 4. Type of Operation: ElDetector Tubes(specify): <br /> ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> S. Release History: ❑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 oractivity/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 ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> -Noise Sources: 19 Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots i <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 /> a Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): <br /> ®Safety vest <br /> ❑Other(specify): <br /> ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART n' <br /> Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Planrepared Y- <br /> PfL t� r <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Date: <br /> Plan Approved by:_ V Date: I J u <br /> i <br /> i <br /> EH 23081 (12/6/2010) i <br /> I <br />