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SITE HEALTH & SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: tVEJ 60ota �A4 Address: 125 Yl4ci x2 p opt !� �Z4'% r Contact Person: M t PA l_ one No: k" I Sweeps Number: Proposed Date of investigation/inspection: evi 1_111-2- 2. 1I1Z 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. ❑ Installation of Borings / Monitoring Wells. Hazardous waste inspection ❑ Sampling Tiered Permitting inspection 3. Specific Site Information: Tank Tank 4. Type of Operation: 'I(tAdr �✓) I (✓Lt at, r-tiryp4•t.r/ 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 and Safety Physical Concerns: (check all that apply & describe) Cl Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): C9,Handling and Transfer of a Hazardous Substance: (fire, explosions, ❑ Confined space entry: (explosions): Heavy equipment (physical injury & trauma resulting from moving ❑ Other, 7. Anticipated Biological Hazards: Q'Snakes OInsects ❑ Rodents ❑ Poisonous 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 (02/19/03) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards (N Cammogens:_ Corrosives:_ ® Dusts: ® Explosives:_ [;J Flammables:_ ❑ Inorganic Gases ❑ Metals: ❑ Oxidizers:_ ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoting 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. ❑ Other, specify. 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 ® Safety vest. ❑ Two-way communication, PART IV - PLAN APPROVAL Plan Prepared by: M Naldu Date:(�— ENVIROLENTAL HEALTA)EPARTMENT rA` Plan Approved by: R V z . SAN JOAQUIN COUNTY °ti'•..?. •'�P et Poa� Donna K. Heron, R.E.H.S. S 304 East Weber Avenue, Third Floor Program Coordinators Carl Borgman, R.E.H.S.Director Laurie A. Co[ulla, R.E.H.S. Stockton, California 95202 Mike Hu Huggins, R.E.H.S., R.D.I. Assistant Director Telephone: (209) 468-3420 Kasey L. Foley, R.E.H.S. Fax: (209) 464-0138 Margaret Lagorio, R.E.H.S. Robert McClellon, R.E.H.S. Web: www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. SITE HEALTH & SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: tVEJ 60ota �A4 Address: 125 Yl4ci x2 p opt !� �Z4'% r Contact Person: M t PA l_ one No: k" I Sweeps Number: Proposed Date of investigation/inspection: evi 1_111-2- 2. 1I1Z 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. ❑ Installation of Borings / Monitoring Wells. Hazardous waste inspection ❑ Sampling Tiered Permitting inspection 3. Specific Site Information: Tank Tank 4. Type of Operation: 'I(tAdr �✓) I (✓Lt at, r-tiryp4•t.r/ 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 and Safety Physical Concerns: (check all that apply & describe) Cl Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): C9,Handling and Transfer of a Hazardous Substance: (fire, explosions, ❑ Confined space entry: (explosions): Heavy equipment (physical injury & trauma resulting from moving ❑ Other, 7. Anticipated Biological Hazards: Q'Snakes OInsects ❑ Rodents ❑ Poisonous 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 (02/19/03) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards (N Cammogens:_ Corrosives:_ ® Dusts: ® Explosives:_ [;J Flammables:_ ❑ Inorganic Gases ❑ Metals: ❑ Oxidizers:_ ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoting 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. ❑ Other, specify. 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 ® Safety vest. ❑ Two-way communication, PART IV - PLAN APPROVAL Plan Prepared by: M Naldu Date:(�— rA` Plan Approved by: R V 1 Date: