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f•�� f N.. X:< ENVIRON ENTAL HEALTH D ARTMENT �: C��IPOiRti�7 Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators 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 PART II GENERAL SITE ORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: % �11 Address: S f . Contact Person: Phone #: 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 "5"dous Waste inspection ❑ Tiered Permitting inspection Chemicals Hazards Carcinogens: ❑ Corrosives: ❑ Dusts: ❑ Explosives: ❑ Flammables: Z organic Gases: Metals: Inorganic rk4eun ❑ PCBs: -TROther: �2 PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipment (Note: Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): Other.: ❑ Combustible Gas/Oxygen Meter ❑ Detector Tubes (specify): 4. Type of Operation: ❑ Photo ionization Detector v�1� r ,� �� ❑ Organic Vapor Analyzer 5. Release History: K '[J ❑ mer (s ecify) 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: C]Oxygen Deficiency: F]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): Anticipated Biological Hazards: C1Snakes Insects ElRodents C3Poisonous Plants C]Other/Unlmown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (5/5/2011) P None (see below) If monitoring instruments are not used, rationale or activity/area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B Cl C ® D ® 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 PooyL _ ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepared b Date: a/t� Plan Approved by:y Date: