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D�qurry <br />' <br />EN'VIR( MENTAL <br />HEALTODEPARTMErNrf <br />SAN JOAQUIN COUNTY <br />cR' ••.,..• '�P <br />trFoa`' <br />Donna K. Heran, R.E.H.S. <br />304 East Weber Avenue, Third Floor <br />Program Coordinators <br />Cart' Borgman, R.E.H.S. <br />Director <br />Laurie A. Cotulla, R.E.H.S. <br />Stockton, California 95202 <br />Mike Huggins, R.E.H.S., R.D.I. <br />Assistant Director <br />Telephone: (209) 468-3420 <br />Kasey L. Foley, R.E.H.S. <br />Fax: (209).464-0138 <br />Margaret Lagorio, R.E.H.S. <br />Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/chd <br />Jeff Carruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE <br />�INFORMATION <br />. y <br />1. Site Name:_ � ?,,t4 Ute"• r L'1 <br />Address: 110ft I 'LO . R r-% <br />Contact Person:p� &ffrtuMf Plnone No: (2,M) 7i <br />Sweeps Number: f <br />Proposed Date of investigation/unspection:_ I D 1 2 f <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation- ❑ UAR Investigation. <br />❑ Tank Clusure in Place- ❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. ❑ Re -excavation. <br />❑ installation of Borings / Monitoring Welts. <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 />4. Type of Operation: <br />Iq <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 ternp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (lure, explosions, <br />❑ Confined space cat y: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify: - - <br />Anticipated Biological Hazards: <br />%Snakes Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (spccify): <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, e1c.) <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 />Flarmnabfes:` <br />Inorganic Gases <br />❑ Metals: <br />❑ Oxidizers:_ <br />El PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equiptnent (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 ® D <br />❑ Hard Hat, <br />Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />2 Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />❑ Two-way communication <br />PART I V - PLAN APPROVAL <br />Plan Prepared by: M Naidu Date: _L0 71 <br />1 tl <br />Plan Approved by: 11 \ l Date: <br />