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z ENVIRON• ENTAL HEALTH DEPARTMENT <br />'vroha(�. <br />Donne K. Heran, RE.H.S. 8 SAN JOAQUIN COUNTY Program Coordinators <br />Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Robert McClellon, R.E.H.S. <br />Jeff Camtesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL <br />1. Site Na <br />Contact Person; / <br />Phone p: <br />Proposed Date of investigation/insper <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 />❑`Sampling <br />C1 Boring /Monitoring Well installation <br />IXHazardous Waste inspection <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: <br />Tank Age: <br />4. Type of Operation: 1-1-A" 11dd--m— <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 & Safety Physical Concerns: (✓ all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />`,c. ccavation (falls, trips, slipping, cave-ins): <br />y(J Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />,❑ Confined space entry (explosions): <br />Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />makes XInsects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 (8/112011) <br />PART H <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />gcarcinogens:,4 <br />❑ Corrosives:_ <br />❑ Dusts: <br />■ <br />Flarrunables <br />■ <br />■ <br />❑ Oxidiz <br />❑ PCBs: <br />❑ Other: <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 />one (see below) <br />If mor. <br />nitoring instruments are not used, rationale or activity/area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C <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 ❑ SCBA <br />A/P Cartridge: <br />WSafety vest <br />o -way communication <br />❑ Other (specify): <br />Ir r <br />WE <br />PART IV <br />PLAN APPROVAL <br />or <br />Plan Prep Date: 9� <br />Plan Approved by: ��1) 1 Date: <br />