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PART GENERAL SITE INFORMATION 1. Site Name: Address: 6t'�C_yid A'i i) tS Contact Person: Phone No: Sweeps Number: Proposed Date of investigation/inspection:' 2. Description and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Rexexcava` ❑ Installation of Borings / Monitoring Wells. 3. Specific Site Information: Tank No.: Tank Content: Other: 4. Type of Operation: Tank Capacity: Tank Age: 5. Release History: Evidence of leaks / soil contamination: ❑ YES E;rNO Documented Groundwater contamination: ❑ YES O 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): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): Other, specify VrJ +.t"4 vQ my 7. Anticipated Biological Hazards: El Snakes S Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. NNarrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (12/17/2002) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards [+Carcinogens: ❑ Corrosives: _ ®°Dusts: ❑ Explosives: [2/Flammables: _ ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: _ ❑ PCB's: 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. 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. r O Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ❑ Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ❑ Safety vest. [j'wo-way communication. PART IV - PLAN APPROVAL Plan Prepared by: h �® Date: Z f Plan Approved by: t Date: ��Cv ENVIRAMENTAL HEALTRDEPARTMENT PpUtN cot SAN JOA UIN COUNTY 2�o,i�� Donna K. Heran, R.E.H.S. 304 East Weber Avenue, Third Floor Unit Supervisors Carl Borgman, R.E.H.S. Director Al Olsen, R.E.H.S. Stockton, California 95202-2708 Mike Huggins, R.E.H.S., R.D.I. cq;.P Program Manager Telephone: (209) 468-3420 Douglas W. Wilson, R.E.H.S. Margaret Lagorio, R.E.H.S. i F o a Laurie A. Cotulla, R.E.H.S. Program Manager Fax: (209) 464-0138 Robert McClellon, R.E.H.S. Mark Barcellos, R.E.H.S. SITE HEALTH AND SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: Address: 6t'�C_yid A'i i) tS Contact Person: Phone No: Sweeps Number: Proposed Date of investigation/inspection:' 2. Description and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Rexexcava` ❑ Installation of Borings / Monitoring Wells. 3. Specific Site Information: Tank No.: Tank Content: Other: 4. Type of Operation: Tank Capacity: Tank Age: 5. Release History: Evidence of leaks / soil contamination: ❑ YES E;rNO Documented Groundwater contamination: ❑ YES O 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): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): Other, specify VrJ +.t"4 vQ my 7. Anticipated Biological Hazards: El Snakes S Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. NNarrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (12/17/2002) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards [+Carcinogens: ❑ Corrosives: _ ®°Dusts: ❑ Explosives: [2/Flammables: _ ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: _ ❑ PCB's: 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. 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. r O Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ❑ Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ❑ Safety vest. [j'wo-way communication. PART IV - PLAN APPROVAL Plan Prepared by: h �® Date: Z f Plan Approved by: t Date: ��Cv