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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:SRI/Surgical Express 1. Chemicals Hazards <br /> Address:6801 Longe St.,Stockton <br /> ®Carcinogens: <br /> Contact Person:Phillip Nagata Phone No:982-5800 ❑Corrosives: <br /> Sweeps Nurtiber: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection:3memar2A94 ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> ❑Hazardous waste inspection ❑ Sampling PART III <br /> X Tiered permit inspection <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. 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 /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:Medical Laundry ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: [I Other,specify. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO Camera,ph paper,sampling equipment <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C OD <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ®Heat or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑ <br /> ❑Excavation:(falls,trips,slipping,cave-ins): Tyvek. <br /> ❑ ❑ ❑ <br /> EJ Handling and Transfer of a Hazardous Substance:(fire,explosions, Respirator: APR SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> Plan Prepared by:Ray von Flue Date:12/22/03 <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by: Date:12/22/03 <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />