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OPq,U rly <br />c� EN'VIRO MENTAL HEALT#DEPARTMENT <br />:Z i N <br />. r - SAN JOAQUIN COUNTY <br />ota�'vr Donna K. Heran, R.E.H.S. 304 East Weber Avenue, Third Floor <br />Program Coordinators <br />Carl Borgman, R.E.H.S. <br />Director <br />Laurie A. Cotulla, R.E.H.S. Stockton, California 95202 <br />Mike Huggins, R.E.H.S., R.D.I. <br />Assistant Director Telephone: (209) 468-3420 <br />Kasey L. Foley, R.E.H.S. <br />Margaret Lagorio, R.E.H.S. <br />Fax: (209).464-0138 <br />Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/ehd <br />Jeff Carruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: <br />Address: <br />Contact Pei -son: 11_1 Y 1.,rA-. sone No: (*05 1 &K % - l0 %O <br />Sweeps Number: <br />Proposed Date of investigation/inspection:�2rd I T Z <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation.. ❑ UAR Investigation. <br />❑ Tank Closure in Place.. ❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. ❑ Re -excavation. <br />❑ Installation of Borings / Monitoring Wells. <br />❑ Hazardous waste inspection ❑ Sampling <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: 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: OF (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 />❑ Confined space entry: (explosions): <br />IX Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify: <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 IH <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 ❑ C N D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />N Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />N Safety vest. <br />❑ Two-way communication. <br />PART IV - PLAN APPROVAL <br />Anticipated Biological Hazards: ' Z <br />Plan Prepared by: M Naidu Date: <br />❑ Snakes P Insects ❑ Rodents ❑ Poisonous Plants ' I <br />❑ Other/Unknown (specify): Plan Approved b U <br />pp y: Date: <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 />