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"'Q q I r: ENVIR10AIENTAL HEALTH DAVARTMENT •cq�5awii'P. SAN JOAQUIN COUNTY Program Coordinators Donna K.Heran,R.E. S. Director 600 East Main Street, Stockton, California 95202 Kase y 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 INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: `A 11>r+ 4�04k 1. Chemicals Hazards Address: o -f' 4 El Carcinogens: Contact Person: _ 4---c— El Phone#: 6 ❑Dusts: Proposed Date of investigation/inspect on: gr-1 1, G-1 ❑Explosives: ❑Flammables: 2. Description and brief narrative of insIx ction activity: ❑Inorganic Gases: ❑New UST installation ❑U AR Investigation ❑Metals: ❑Tank Closure in Place 0T' T ipe Repair ❑Oxidizers: F1Tank/Pipe Removal ❑R -excavation ❑PCBs: ❑Sampling ❑B ring/Monitoring Well installation ❑Other: �Iazardous Waste inspection C3 ered 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: 1Mv GNrz, ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) Documented Groundwater contaminate n: C]YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any pre 'ous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Con ems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD ❑Heat or Cold Stress: °F igh ambient temp.) ®Hard Hat F1 Noise Sources: ®Safety Glasses/Goggles El Oxygen Deficiency: ®Steel toed/shank shoes or boots excavation(falls,trips,slipping,cav ins): ❑Flame retardant coveralls ,Handling and Transfer of a Hazardo Substance(fire,explosions,etc.):. ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA A/P Cartridge:-::�eavY equipment(phsical injury Y& ma resulting from moving equipment): ®Safety vest ❑Other(specify): ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by. Date: e.g.,power lines,integrity of dikes,terra ,etc.): 1 ` I Plan Approved by:�— V Date: 1` EH 23081(6/22/2011)