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Pqu 1(y z Z ENVIRON ENTAL HEALTH DEPARTMENT ..C,OQ-Fi �P Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY program Coordinators Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. 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,RE.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1. Chemicals Hazards Address: �Careinogens:t 1121 x�-(T)i-X1. 1 t_ylaq,�, Contact Person: ElCorrosives: Phone#: Z.I ❑Dusts: Proposed Date of mvestigation/inspection: 06 I3 11 ❑Explosives: ❑Flammables: 2. Description and brief narrative of inspection activity: 215organic Gases: Z. ❑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. �"zarWaste inspection ❑Tiered Permitting inspection dous PART III 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): 4. Type of Operation:l 1 x h &Oa&A.C 4 ❑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: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots ❑Excavation(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 ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): ®Safety vest ❑Other(specify): ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL �/, 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: �1,L �1--� A--y Date: e.g.,power lines,integrity of dikes,terrain,etc.): 1'�j ]�j r Plan Approved by: V 1 Date: EH 23081(5/9/2011)