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S�tybA�e�3 < ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY program Coordinators Donna K.Reran,R.E.H.S. Director 600 East Main Street, Stockton, California 95202 Kase Y L.Foley,R.E.H.S. Telephone.(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. Jeff Caattesco,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 INFORMAPON,t EVALUATION OF POTENTIAL HAZARDS 1. Site Name- ��//i[/J �,` I. Chemicals Hazards Address: � �✓ - ❑Carcinogens: Contact Person: ❑Corrosives: Phone r7: ❑Dusts: Proposed Date of investigation/inspection: 27 ❑Explosives: 2. Description and brief narrative of inspection activity: 0 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: - *--dour Waste inspection El Tiered Permitting inspection 777777�� PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipmwt(Note:Monitoring instruments must be used for all Tank Contest: Tank Age: operations unless appropriate rationale or restrictions are provided): Other. ❑Combustible Gas/Oxygen Meter ! ❑Detector Tubes(specify): 4. Type of Operation: k -1'la ,] y�� ❑Photo ionization Detector v ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO one(see below) Documented Groundwater contamination: ❑YES [I NO If mo toting instruments are not used,rationale or activity/area restrictions: Background and description of any previous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots ) ' xcavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA XHeavy equipment(physical injury&trauma resulting from moving A/P Cartridge: 4uipment): ®Safety vest I ❑Other(specify): Two-waycommunicationpl,, avuor ❑Other(specify): 7. Anticipated Biological Hazards: Snakes Insects Rodents ❑Poisonous Plants PART IV ❑OthedUnlmown(specify): PLAN APPROVAL 8. Narrative Narrative(provide all information which could impact Health and Safety, Plan Prepared b . Date: e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved by: L Dat EH 23081(5/52011)