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Donna K. Heran, R.E.H.S. <br />Director <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />Web: www.sjgov.org/ehd <br />Program Coordinators <br />Kasey L. Foley, R.E.H.S. <br />Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S. <br />2. Description and brief narrative of inspection activity: <br />0 New UST installation <br />0 Tank Closure in Place <br />0 Tank/Pipe Removal <br />0 Sampling <br />laHazardous Waste inspection <br />0 UAR Investigation <br />0 Tank/Pipe Repair <br />0 Re-excavation <br />0 Boring / Monitoring Well installation <br />0 Tiered Permitting inspection <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />I. Monitoring Equipment (Note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided): <br />0 Combustible Gas/Oxygen Meter <br />0 Detector Tubes (specify): <br />0 Photo ionization Detector <br />0 Organic Vapor Analyzer <br />0 Other (specify): <br />0 None (see below) <br />If monitoring instruments are not used, rationale or activity/area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: OA OB 0 C El D <br />Hard Hat <br />Safety Glasses/Goggles <br />El Steel toed/shank shoes or boots <br />0 Flame retardant coveralls <br />El Hearing protection <br />0 Tyvek <br />0 Respirator: 0 APR SCBA <br />A/P Cartridge: <br />El Safety vest <br />IF Two-way communication <br />0 Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: v:)....-Ld <br />Plan Approved by: IAA <br />Date: e,c,-2.1-0 <br />Date: <br /> <br />SITE HEALTH & SAFETY PLAN <br />PART I PART II <br />0 Corrosives: <br />12 Dusts. <br />C glq <br /> 0 Explosives: <br />0 Flammables: <br />0 Inorganic Gases: <br />D Metals: <br />0 Oxidizers: <br />0 PCBs: <br />Other: <br /> <br />GENERAL SITE INFORMATION , EVALUATION OF POTEN <br />1. <br /> <br />Site Name: k.41 jo ai rt-firs Al Y 141Y1 I. Chemicals Hazards <br />Address: f: LA:5111 <br />Contact Person: ja rViA 1 te-t,t/0414-1115 <br />Phone #: Z (I 1 qui <br />Carcinogens: (Afadei -RA,vvtavtiLiktVir, C11;41k <br />L HAZARDS <br />Proposed Date of investigation/inspection: <br />Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age. <br />Other: <br />Type of Operation:0 chthisYN <br />Release History: <br />Evidence of leaks / soil contamination: 0 YES 0 NO <br />Documented Groundwater contamination: 0 YES 0 NO <br />Background and description of any previous investigation or incidence: <br />6 Potential Health & Safety Physical Concerns: (./ all that apply & describe) <br />Heat or Cold Stress: °F (high ambient temp.) <br />Noise Sources: <br />Oxygen Deficiency: <br />0 Excavation (falls, trips, slipping, cave-ins): <br />0 Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />Confmed space entry (explosions): <br />0 Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />0 Other (specify): <br />Anticipated Biological Hazards: <br />0 Snakes 0 Insects 0 Rodents 0 Poisonous Plants <br />0 Other/Unknown (specify): <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (8/6/2010)