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�o to amu' �"_?'; ..co � zENVIRONI', ENTAL HEALTH D#ARTMENT a: SAN JOAQUIN COUNTY program Coordinators Donna K. Heran, RE.H.S. 600 East Main Street, Stockton, California 95202 Robert L. Foley, McClellon, E.H.S. Director Robbert , R.E.H.S. Telephone: (209) 468-3420 Fax: (209) 468-3433 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: Address: v W ZLZU Contact Person: y4I&MZ Phone #: " 9� X L7J 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 13CRazardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: O&JveiE M�r. 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): Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): �qeavy equipment (physical injury & trauma resulting from moving uipment): ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes '%Insects ❑ Rodents ❑ Poisonous Plants ❑ OthWUnlmown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (3/5/2012) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards ❑ Corrosives: ❑ Dusts: ❑ Explosives: Date: a 3 �Flammables: ' / � twl-t Inorganic Gases; ❑ Metals: Oxidizers: ❑ PCBs: Other: :E![]95:) CD 04 h7 l,f YJO n/IlJ Ccn t rx?; U 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 E 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 b'wo-way communication ❑ Other (specify): I r IC'LC PART IV PLAN APPROVAL Plan Prepared Date: a 3 Plan Approved by: Date.