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ENVIRONMENTAL HEALTH DEPARTMENT Cq''••,....••��P SAN JOAQUIN COUNTY Program Coordinators Donna K.Heran,R.E. .S. Kasey L.Foley,R.E.H.S. Director 1868 E. Hazelton Ave., Stockton,California 95205 Robert McClellon,R.E.H.S. Telephone:(209)468-3420 Fax:(209)468-3433 Jeff Carruesco,R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte,R.E.H.S. Rodney Estrada,R.E.H.S. SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,R.E.H.S. PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: i 3t-z�-11. �emicals Hazard Address: Carcinogen 'tr✓ v Contact Person: ❑Corrosives: Phone#: ❑Dusts: Proposed Date of investigation/inspec ion: a ❑Explosives: lammables: ea-z , 2. Description and brief narrative of ins ction activity: ?Inorganic Gases: ❑New UST installation ❑I 1AR Investigation ❑Metals: ❑Tank Closure in Place ❑I ank/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑F e-excavation ❑PCBs: ❑Sampling ❑E oring/Monitoring Well installation ❑Other: P'4-Iazardous Waste inspection ❑I iered Permitting inspection ❑Hazardous Materials Business Plar PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 3. Specific Site Information: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank No.: T ink Capacity: operations unless appropriate rationale or restrictions are provided): Tank Content: T ink Age: ❑Combustible Gas/Oxygen Meter Other: ❑Detector Tubes(specify): ❑Photo ionization Detector 4. Type of Operation: _ ❑Organic Vapor Analyzer ❑Other(specify): 5. Release History: Ione(see below) Evidence of leaks/soil contamination: [I YES El NO If mo/nito_ring instruments are not used,rationale or activity/area restrictions: Documented Groundwater contaminate n: ❑YES ❑NO Background and description of any pre iious investigation or incidence: 2. Personal Protective Equipment Level of Protection: ❑A ❑B ❑C 6. Potential Health&Safety Physical Con cems:(check all that apply& ❑Hard Hat describe) ❑Safety Glasses/Goggles ❑Heat or Cold Stress: °F high ambient temp.) �teel toed/shank shoes or boots ❑Noise Sources: ❑Flame retardant coveralls ❑Oxygen Deficiency: ❑Hearing protection excavation(falls,trips,slipping,cai a-ins): ❑Tyvek Xand Transfer of a Hazard s Substance(fire,explosions,etc.): El Respirator: El APR ElSCBA � " A/P Cartridge: ❑Confined space entry(explosions): ❑Safety vest 'Weavy equipme (physical in'ury trauma resulting from moving ❑Two-way communication equipment): D ❑Other(specify): ❑Other(specify): PART W 7. Anticipated Biological Hazards: PLAN APPROVAL ❑Snakes >nsects ❑Rodents ❑Poisonous Plants ❑Other/Unknown(specify): Plan Prepared by: — Date: 8. Narrative(provide all information whicl i could impact Health and Safety, plan Approved by: Dater 3 1 e.g.,power lines,integrity of dikes,tern in,etc.): EH 23081 (4/30/2013)