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o4a"In r.' e: m: •�.�,CIFtSPerP 0 0 ENVIRONMENTALSAN JOAQUIN COUNTY Program SAN Coordinators Donna K Heran, R.E.H.S. Kase L. Foley, R.E.H.S. Director 600 East Main Street, Stockton, California 95202 Y Y. Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. SITE HEALTH & SAFETY PLAN PART GENERAL SITE INFORMAT.WN 1. Site Name: I &M t&? 0; I /1 Address: S:4 N ` , I ✓ v Contact Person: q�� Phone #: �_ —W !4 Proposed Date of investigation/inspection:�, sit V 2. Description and brief narrative of inspection activity: ❑ New UST installation ❑ GAR 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: 4. Type of Operation: V ! �5 "7t. r t^_'J 5. Release History: Evidence of leaks / soil contamination: ❑ YES [&NO Documented Groundwater contamination: ❑ YES ❑ NO PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards ❑ Corrosive R1 Dusts:_ ❑ Explosive Flammabl ❑ Inorganic ❑ 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 ❑ Other (specify): ❑ None (see below) LL+_Ir, If monitoring instruments are not used, rationale or activity/area restrictions: Background and description of any previous investigation or incidence: Potential Health & Safety Physical Concerns: (✓ all that apply & describe) Heat or Cold Stress: OF (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): ryHeavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ 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.): 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ® 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 ❑ Two-way communication ❑ Other (specify): ■� PART IV PLAN APPROVAL Plan Prepared by: `` Date: 4A 31 I Plan Approved by: Date: