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aPgU(N f` 2, y ENVIRON NTAL HEALTH D A ARTMENT • Cq'`iFQ,�a�P 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 GENERAL SITE INFORMATION 1. Site Name: OI W PIX9 Address: 0"a5 WG Contact Person: Phone #: Proposed Date of investigation/inspection: 2. Description and brief narrative of inspection activity: ❑ New UST installation ❑ Tank Closure in Place ❑ Tank/Pipe Removal ❑ Sampling Hazardous Waste inspection ❑ UAR Investigation ❑ Tank/Pipe Repair ❑ Re -excavation ❑ Boring / Monitoring Well installation ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: Ye/S k M k- 5. 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: Q'Excavation (falls, trips, slipping, cave-ins): andling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): Meavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: �n;akes Insects Rodents ❑ Poisonous Plants U �►er/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (8/11/2011) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards Marcinogens: 6V on-osives: ❑ Dusts: ❑ Explosives: Fhunmables: Inorganic Gases: ❑ Metals: Oxidizers: N ❑ PCBs: Other: le!T 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): 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 ® Steel toed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR A/P Cartridge: ❑ SCBA ® Safety vest ��,, ``,�,, ,�,, UL 'Two-way communication I—rt�CJV_ ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepare Date: Plan Approved by: Date: