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O.p4ulN• C t: ENVIRIDAIENTAL HEALTH DSARTMENT Cq�iFORi��P Donna K.Heran,R.E.H S. SAN JOAQUIN COUNTY program Coordinators Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. Web:www.sgov.org/ehd Jeff Carruesco,R.E.H.S.j Linda Turkatte,R.E.H.S. SITE HEALTH& SAFETY PLAN PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS L Site Name: 0 1. Chemicals Hazards Address: i Carcinogens:6 t-} Contact Person: ya33 ❑Corrosives: Phone#: �ZV!2--ZC713 ❑Dusts: Proposed Date of investigation/inspect' n: ❑Explosives: ,anammables: 2. Description and brief narrative of inspe tion activity: Inorganic Gases: ❑New UST installation ❑UAR Investigation ❑Metals: ❑Tank Closure in Place ❑T Pipe Repair Oxidizers:E6LW.3 ❑Tank/Pipe Removal ❑R -excavation ❑PCBs: ❑Sampling ❑ B ring/Monitoring Well installation ❑Other. *azardous Waste inspection ❑Ti Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Ta nk Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank Content: T k Age: operations unless appropriate rationale or restrictions are provided): Other: ❑Combustible Gas/Oxygen Meter ❑Detector Tubes(specify): 4. Type of Operation: ❑Photo ionization Detector ❑Organic Vapor Analyzer 5. Release History: ❑Other(specify): Evidence of leaks/soil contamination: ❑YES ❑NO None(see below) Documented Groundwater contaminati : ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Background and description of any previous investigation or incidence: 2. Personal Protective Equipment 6. Potential Health&Safety Physical Con ems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ED ❑Heat or Cold Stress: °F(iigh ambient temp.) ®Hard Hat `Noise Sources: ®Safety Glasses/Goggles ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots Excavation(falls,trips,slipping,cav -ins): ❑Flame retardant coveralls Handling and Transfer of a Hazardot s Substance(fire,explosions,etc.): ®Hearing protection ❑Tyvek ❑Confined space entry(explosions): ❑Respirator: ❑ APR ❑SCBA Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: equipment): Safety vest ❑Other(specify): wo-way communication rf19rLe-,-* ❑Other(specify): 7. Anticipated Biological Hazards: 15XSnakes 156nseets�Rodents ❑Poisonous Plants PART IV ❑Other/Unknown(specify): PLAN APPROVAL 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved by: 1 Date: I EH 23081(12/16/2011)