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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE HEALTH AND SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: ToK- S P_ S <br />Address: 1112--f A"9�1 C_ t <br />Contact Person:(LE,) MAC*AOfl�J Phone No: 46'S-491'1.— <br />Sweeps Number: <br />Proposed Date of investigation/inspection: S � -� (-0(::, <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation.. <br />❑ UAR Investigation. <br />❑ Tank Closure in Place.. <br />❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. <br />❑ Re -excavation. <br />❑ Installation of Borings / Monitoring <br />Wells. <br />Hazardous waste inspection <br />❑ Sampling <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: <br />Tank Age: <br />Other: <br />4. Type of Operation:. <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents <br />❑ Other/Unknown (specify): <br />❑ Poisonous Plants <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 />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />Carcinogens: _ <br />❑ Corrosives: _ <br />Dusts: <br />Explosives: <br />Flammables: <br />❑ Inorganic Gases: <br />,Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B <br />Hard Hat. <br />`Safety Glasses/goggles. <br />Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR <br />cartridge: <br />In Safety vest. <br />❑ Two-way communication. <br />M"d <br />❑ SCBA <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: U ' ` (A Date: _ 2.)( �v <br />Plan Approved by: Date: JI3 ( 6 <br />