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0.Pau1N' c, ).• �'•.0 AARTMENT E VI OMENTAL HEALTH c4t:IF60i4 SAN JOAQUIN COUNTY Donna K. H ran, R.E. Program Coordinators S. Di ctor 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. 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/INFO ATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: W / or? 1i 07 1. Chemicals Hazards Address: ,/ carcinogens: I.1 Sed C 1 I Contact Person: ❑ Corrosives: Phone #: C E3 Dusts: Proposed Date of investi ation/insp tion: �/ /o /' 3/ /D ❑ Explosives: ❑ Flammables: 2. Description and brief narrative of inspection activity: tg-hrorganic Gases: rYPcpr-7 ❑ New UST installatior ❑ UAR Investigation ❑ Metals: ❑ Tank Closure in Plac4 ❑ Tank/Pipe Repair ❑ Oxidizers: ❑ Tank/Pipe Removal ❑ Re -excavation )& PCBs: !S/ ❑ Sampling ❑ Boring / Monitoring Well installation ❑ Other: Hazardous Waste insl ection ❑ Tiered Permitting inspection PART III 3. Specific Site Information REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: ank Capacity: 1. Monitoring Equipment (Note: Monitoring instruments must be used for all Tank Content: ank Age: operations unless appropriate rationale or restrictions are provided): Other: ❑ Combustible Gas/Oxygen Meter ❑ Detector Tubes (specify): 4. Type of Operation: �� /� �!7�X �4 �/e ❑Photo ionization Detector ❑ Organic Vapor Analyzer 5. Release History: Other (specify): Evidence of leaks / soil contamination: ❑ YES ❑ NO one (see below) Documented Groundwater contamin ion: ❑ YES ❑ NO If monitoring instruments are not used, rationale or activity/area restrictions: Background and descripti n of any previous investigation or incidence: 6. Potential Health & Safety Physical ❑ Heat or Cold Stress: ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation (falls, trip slipping, Handling and Transfer of a Haza ❑ Confined space entry ❑ Heavy equipment (ph ❑ Other (specify): 7. Anticipated Biological H rd: ❑ Snakes Insects ❑ ❑ Other/Unkn/o_wn (speci ,cems: (✓ all that apply & describe) (high ambient temp.) Substance (fire, explosions, etc.): injury I&, trauma resulting from moving 8. Narrative (provide all info f oration e.g., power lines, integrity f dikes, EH 23081 (9/15/2010) ❑ Poisonous Plants could impact Health and Safety n, etc.): 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ® Hard Hat ® Safety Glasses/Goggles ® Steel toed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR ❑ SCBA A/P Cartridge: ® Safety vest Two-way communication VL1 O ri-r— ❑ Other (specify): PART IV PLAN APPROVAL �o? /O Plan Prepar b.. Date: Plan Approved by: Date: