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PqU{,N ENVI OMENTAL HEALTH AARTMENT C9��PORa�P Donna K.Heran,R.E. 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,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL SITE 14FORMATLQN EVALUATION OF POTENTIAL HAZARDS 1. Site Name: L Chemicals Hazards Address: 1E2 N/ ❑Carcinogens: Contact Person: h ❑Corrosives: Phone#: ❑Dusts: Proposed Date of investigation/inspec'on: ❑Explosives: / I Wlammables: 7y 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: ❑New UST installation ❑I JAR Investigation ❑Metals: ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: ❑Tank/Pipe Removal ❑I I e-excavation ❑PCBs: ❑Sampling ❑ oring/Monitoring Well installation ❑Other: azardous Waste inspection ❑ iered Permitting inspection PART III 3. Specific Site h►formation: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: T ink Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: T ink 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: ❑Other(specify): Evidence of leaks/soil contamination: ElYES [3NOfone(see below) Documented Groundwater contamina n: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any p ious investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Coi ceras:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD ❑Heat or Cold Stress: OF(high ambient temp.) ®Hard Hat ❑Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots Excavation(falls,trips,slipping,ca a-ins): ElFlame retardant coveralls andling and Transfer of a Hazard Substance(fire,explosions,etc.):. ®Hearing protection ' J ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA �eavy equipment(physical injury trauma resulting from moving A/P Cartridge: uipment): ®Safety vest ❑Other(specify): )''wo-way communication p f 1 ol'-' ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes 15,Asects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information whic could impact Health and Safety, Plan Prepared b Date: e.g.,power lines,integrity of dikes,t in,etc.): ` I Plan Approved by: Dater EH 23081(3/5/2012)