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P4t�rN., <br /> ENVIR N ENTAL HEALTH WdeARTMENT <br /> Donna K.Heran,R.E.H. . SAN JOAQUIN COUNTY Program Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION �+ EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: J 1. Chemicals Hazards <br /> Address: 01farcinogens: SD7�� <br /> Contact Person: e ❑Corrosives: <br /> Phone#: O / 2 ❑Dusts: <br /> Proposed Date of investigation/inspecti n: We'll ti ❑Explosives: <br /> KFlammables• <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Ta WPipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑R -excavation ❑PCBs: <br /> Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> dous Waste inspection ❑Ti ed Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: T Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: T Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO None(see below) <br /> Documented Groundwater contaminatio : ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any prev ous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Con s:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ❑Heat or Cold Stress: °F(iigh ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> xcavation(falls,trips,slipping,cave-ins):_ ❑Flame retardant coveralls <br /> tX-dling and Transfer of a HazardousSubstance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> eavy equipment( hysic�al' j & uma resulting from moving <br /> A/P Cartridge: <br /> quipment): Safety vest�� <br /> ❑Other.(specify): N4wo-way communicatio <br /> ❑Other(specify): <br /> 7. ipated iological Hazards: <br /> 9rakes Insects Rodents ❑Poisonous Plants PART IV <br /> [IOther/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: Z 4 <br /> e.g.,power lines,integrity of dikes,tenraj ri,etc.): <br /> Plan Approved by: Date: <br /> EH 23081(5/5/2011) <br />