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to�'A!py <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> hi Donna K.Henan,R.E.H.S. 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 /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: VIrWA11\11" 1. Chemicals Hazards <br /> Address: 12,b-2- 11 RN,QFV U PAtPA lqf'4k) �A Carcinogens: F-ULZ <br /> Contact Person: n Corrosives: <br /> Phone#: l n Dusts: <br /> Proposed Date of investigation/inspection: E]Explosives: <br /> F1 Flammables: <br /> 2. Description and brief narrative of inspection activity: [I hiorganic Gases: <br /> El New UST installation ❑UAR Investigation 0 Metals: <br /> n Tank Closure in Place ❑Tank/Pipe Repair 0 Oxidizers: <br /> FlTank/Pipe Removal n Re-excavation 0 PCBs: <br /> F1 Sampling ❑Boring/Monitoring Well installation El Other: <br /> ]Hazardous Waste inspection ❑Tiered Permitting inspection PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: []Combustible Gas/Oxygen Meter <br /> nDetector Tubes(specify): <br /> 4. Type of Operation: AN C10409-4Z 0 Photo ionization Detector <br /> 0 Organic Vapor Analyzer <br /> 5. Release History: F]Other(specify): <br /> Evidence of leaks/soil contamination: n YES n NO F]None(see below) <br /> Documented Groundwater contamination: C]YES n NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(V all that apply&describe) Level of Protection: n A [I B 0 C 0D <br /> C3 Heat or Cold Stress: 'F(high ambient temp.) 0 Hard Hat <br /> n Noise Sources: 0 Safety Glasses/Goggles <br /> C]Oxygen Deficiency: 0 Steel toed/shank shoes or boots <br /> C]Excavation(falls,trips,slipping,cave-ins): n Flame retardant coveralls <br /> n Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): 0 Hearing protection <br /> El Tyvek <br /> F1 Confined space entry(explosions): C3 Respirator: [3 APR [_1 SCBA <br /> n Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): Safety vest <br /> El Other(specify): Two-way communication QA'fitliv—, <br /> Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> E3 Snakes 0 Insects El Rodents C3 Poisonous Plants PART IV <br /> n Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: gAl-10 <br /> EH 23081(8/6/2010) <br />