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OpyLulfl• C _-4 ENVIRO NTAL HEALTH DOARTMENT ..C�q`;FORa�Q• SAN JOAQUIN COUNTY Program Coordinators Donna K.Heran,R.E.H.S. Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,RE.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,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART H GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: 1. Chemicals Hazards Address: ldCarcinogens: &k. a-a&zeirx—, Contact Person: ❑Corrosives: Phone#: — 2- C3Dusts: Proposed Date of investigation/inspec'on: a_7 3 Z ❑Explosives: Flammables:04401/)U 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑Tank/Pipe Repair (Oxidizer }.yea ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: Sampling LlBoring/Monitoring Well installation ElOther: Dialazardous Waste inspection ❑Tiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: T Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: T Age: operations unless appropriate rationale or restrictions are provided): Other: ❑Combustible Gas/Oxygen Meter ❑Detector Tubes(specify): 4. Type of Operation: ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ElOther(specify): Evidence of leaks/soil contamination: C]YES ElNO '*10one(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 Cot Gems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ED ❑Heat or Cold Stress: OF(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots xcavation(falls,trips,slipping,ca ta-ins): ❑Flame retardant coveralls andling and Transfer of a Hazard us Substance(fire,explosions,etc.):, ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA �eavy equipment(physical injury trauma resulting from moving A/P Cartridge: ttipment): ®safety vest ❑Other(specify): Two-way communication 7'haxie- ❑Other(specify): 7. Anticipated Biological Hazards: U,&es InsectsRoden El Poisonous Plants PART IV ❑Other/Un"(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b Date? Z e.g.,power lines,integrity of dikes,terrain,etc.): PL' Plan Approved by: Date: �V EH 23081(3/5/2012)