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PqurN <br /> z: ENVIROtIENTAL HEALTH D PARTMENT <br /> cq�/Fp.1i��P <br /> Donna K.Heran,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 /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITEORMATI �Nn EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: � r� 'A 1. Chemicals Hazards <br /> Address: G((O 6( b "WL Carcinogens: <br /> Contact Person: TI w An~S Corrosives: <br /> Phone#: Dusts: <br /> Proposed Date of investigation/inspection: Explosives: <br /> t1norganicammables: <br /> 2. Description and brief narrative of inspection activity: Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> 1�/1-Iazardous Waste inspection E]Tiered Permitting inspection <br /> //`` 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 /> C ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑Photo ionization Detector <br /> �- —T ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES NO '&.ne(see below) <br /> Documented Groundwater contamination: ❑YES O 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:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ;� 1MB °F(high ambient temp.) ®Hard Hat <br /> Heat or Cold Stress: �/ <br /> Xoise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): Safety vest <br /> El Other(specify): (Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑SnakesInsects Rodents ❑Poisonous Plants PART IV <br /> f-1 Other/Unknown(speci ): PLAN APP <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: v <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: �y `'� Date: <br />