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RytUI& <br />z ENVIRONMENTAL HEALTH DEPARTMENT <br />f: X <br />SAN JOAQUIN COUNTY <br />c'uFoaa�P Donna K. Heran, R.E.H.S. 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 Carruesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: Plh r0/4 Ssfl <br />Contact Person:_ <br />Phone #: <br />Proposed Date of <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ UAR Investigation <br />❑ Tank Closure in Place <br />[I Tank/Pipe Repair <br />❑ Tank/Pipe Removal <br />❑ Re -excavation <br />❑ Sampling <br />❑ Boring / Monitoring Well installation <br />Pazardous 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 Opecation:pe D &o% Fy �_] Je <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES �!J ❑ NO <br />Documented Groundwater contamination: ❑ YES 0 [:]NO <br />Background and description of any previous investigation or incidence: <br />460 C-INVIIA6 Mk,,C i►G0►P <br />_-. G "I <br />' <br />���/) <br />6. Potential Health & Safety Physical Concerns: (, all aVt'applyt &describe) <br />❑ Heat or Cold Stress: OF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):, <br />❑ <br />Confined space entry (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />❑ Carcinogens: OS <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />❑ Flammables: <br />❑ Inorganic Gases: t� <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />❑ Other. <br />PART III <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 />❑ None (see below) <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 />® Hearing protection <br />❑ Tyvek <br />❑ Respirator: ❑ APR <br />A/P Cartridge: <br />® Safety vest <br />❑ Two-way communication <br />❑ Other (specify): <br />Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants PART IV <br />❑ Other/Unknown (specify): PLAN APPROVAL <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (5/9/2011) <br />❑ SCBA <br />Plan Prepared by: t/ a, Date: 6 <br />Plan Approved by: � J I`' Date: <br />