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Pq,U 1 /y <br />Zj ENVIRONMENTAL HEALTH 10PARTMENT <br />Cq�IFO.Ka;� Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY 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 />J <br />Web: www.sjgov.org/ehd effCarruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: 1. Chemicals Hazards <br />Address: Aarcinogens: <br />Contact Person f Q ❑ Corrosives: <br />Phone #: O ❑ Dusts: <br />Proposed Date of investigation/inspection: ❑ Explosives: <br />*lammables: <br />2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br />❑ New UST installation ❑ UAR Investigation ❑ Metals: <br />❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Oxidizers: <br />❑ Tank/Pipe Removal ❑ Re -excavation ❑ PCBs: <br />❑ Sampling ❑ Boring / Monitoring Well installation ❑ Other: <br />Hazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />4. Type of Operation: OdVAZ� <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />)CExcavation (falls, trips, slipping, cave-ins): <br />andling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />)heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7.nLcipated Biological Hazards: <br />,ElSnakes ,Insects [J�Kdents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (4/7/2010) <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 />Ione (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 ❑ SCBA <br />A/P Cartridge: <br />® Safety vest <br />ATwo-way communication/410 rZ nn � <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared Date:—� <br />�La <br />Plan Approved by: Date: �� 1 <br />