COMPLIANCE INFO PRE 2019 - Laserfiche WebLink

Home Browse Search

PqU l Iy ENVIRO PIMNTAL HEALTH D PARTMENT • OR;;:� . SAN JOAQUIN COUNTY Program Coordinators Donna K. Heran, R.E.H.S. Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. 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 I GENERAL SITE INFORMATION I 1. Site Name: I4I d Address: A W I' av, . . c � Contact Person:_R Ovr1 Phone #: ?.v1 -- 5-44. 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 ❑ Re -excavation ❑ Sampling ❑ Boring / Monitoring Well installation Ol Hazardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: ilV.1� 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 & Safety Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation (falls, trips, slipping, cave-ins): CKHandling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): F5 Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 8. Anticipated Biological Hazards: `n Snakes [MInsects (Rodents F1Poisonous Plants `i❑ Other/Unknown (specify): Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (2/23/2011) PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards (R Carcinogens: [gCorrosives: [R Dusts: ® Explosives: [� Flammables: ❑ Inorganic Gases: ❑ 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) 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 ® Steeltoed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR A/P Cartridge: ® Safety vest ❑ Two-way communication ❑ Other (specify): PART IV PLAN APPROVAL ❑ SCBA Plan Prepared by: MA - AJC►- rk" Date: Plan Approved by: Date: