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PART GENERAL SITE INF RMA,,TIIQN ' e 1. Site Name: Nl t,1(� ' Q� Address: 01 C' -v Contact Person: Phone No: Sweeps Number: Proposed Date of it vestigation/inspection: 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. 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: 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) ❑ Hear or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑Excavation: (falls, trips, slipping, cave-ins): E ]dandling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other, specify Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Other/Unknown (specify): PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards carcinogens: [2 -Corrosives: _ ❑ Dusts: ❑ Explosives: elammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT I . 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. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C Ia ❑ 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. PART IV - PLAN APPROVAL ❑ Poisonous Plants Plan Prepared by: Date: Plan Approved by: 4, , . / Date: 8. Narrative (provide all information which could impact Health and Safety, Kdl e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (12/17/2002) 9 ENVIRONMENTAL HEALTH DEPARTMENT U!, SAN SAN JOAQUIN COUNTY 2 Z `. Donna K. Heran R.E.H.S. Unit Supervisors 304 East Weber Avenue, Third Floor Carl Borgman, R.E.H.S. Director Mike Huggins, R.E.H.S., R.D.I. Al Olsen, R.E.H.S. Stockton, California 95202-2708 c4�iFORP Douglas W. Wilson, R.E.H.S. Program Manager Telephone: (209) 468-3420 Margaret Lagorio, R.E.H.S. Laurie A. Cotulla, R.E.H.S. Fax: (209) 464-0138 Robert McClellon, R.E.H.S. Program Manager Mark Barcellos, R.E.H.S. SITE HEALTH AND SAFETY PLAN PART GENERAL SITE INF RMA,,TIIQN ' e 1. Site Name: Nl t,1(� ' Q� Address: 01 C' -v Contact Person: Phone No: Sweeps Number: Proposed Date of it vestigation/inspection: 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. 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: 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) ❑ Hear or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑Excavation: (falls, trips, slipping, cave-ins): E ]dandling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other, specify Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Other/Unknown (specify): PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards carcinogens: [2 -Corrosives: _ ❑ Dusts: ❑ Explosives: elammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT I . 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. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C Ia ❑ 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. PART IV - PLAN APPROVAL ❑ Poisonous Plants Plan Prepared by: Date: Plan Approved by: 4, , . / Date: 8. Narrative (provide all information which could impact Health and Safety, Kdl e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (12/17/2002)