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o.P4�IN•..c - y ENVIRONMENTAL HEALTH DEPARTMENT • FO.fia;P SAN JOAQUIN COUNTY Program Coordinators Donna K. Heran, R.E.H.S. 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.sjgov.org/ehd Jeff Carruesco, R.E.H.S. SITE HEALTH & SAFETY PLAN PART I GENERAL SITE 1. Site Name: Contact Person: -L Phone #: Proposed Date of 2. Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Tank/Pipe Removal ❑ Re -excavation ❑ Sampling ❑ Boring / Monitoring Well installation Hazardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation:�& \ieS S 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) Noise Sources: ❑ Oxygen Deficiency: Excavation (falls, trips, slipping, cave-ins): Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. ❑ Confined space entry (explosions): Meavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: Snakes Trisects ,Rodents / Paisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (4/7/2010) PART II EVALUATION OF POTENTIAL HAZARDS L Chemicals Hazards azcinogens: Corrosives: Dusts: JFxplosives: �D 1'O SSC r lammables: Inorganic Gases: Metals: Oxidizers: ❑ PCBs: ❑ Other: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (Note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided): ❑ Combustible Gas/Oxygen Meter ❑ Detector Tubes (specify): ❑ Photo ionization Detector ❑ Organic Vapor Analyzer JJ Other (specify): ,1 afl- ?n C ((8i ffuk� ❑ None (see below) If monitoring instruments are not used, rationale or activity/area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® 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 ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepared r1 Date: Plan Approved by: k A� Date: