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PART
<br />GENERAL SITE INFORMATION
<br />1. Site Name: Na -T 6'r %LA,U,.PV'.
<br />Address: tcJA W. c,T�
<br />Contact Person: etr.) LaoYn Phone No: 240,+Wf, 000
<br />Sweeps Number:
<br />Proposed Date of investigation/inspection: oe -3(:>oc
<br />2. Description and brief narrative of inspection activity:
<br />❑ New UST installation. ❑ UAR Investigation.
<br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair.
<br />❑ Tank/Pipe Removal. ❑ Re -excavation.
<br />❑ Installation of Borings /Monitoring Wells.
<br />�tw trsspEc�c-to�
<br />3. Specific Site Information:
<br />Tank No.:
<br />Tank Capacity:
<br />Tank Content: Tank Age:
<br />Other:
<br />4. Type of Operation: rnAiijTwi' JP41)l.6 R.eIP41 R
<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 and Safety
<br />Physical Concerns: (check all that apply & describe)
<br />❑ Hear or Cold Stress: °F (high ambient temp.)
<br />[Noise Sources:—_s��ttv►.tSt:?T
<br />❑ Oxygen Deficiency:
<br />❑ Excavation: (falls, trips, slipping, cave-ins):
<br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions,
<br />etc..):
<br />❑ Confined space entry: (explosions):
<br />❑ Heavy equipment (physical injury & trauma resulting from moving
<br />equipment):
<br />❑ Other, specify
<br />Anticipated Biological Hazards:
<br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants
<br />❑ Other/Unknown (specify):
<br />8. Irrative (provide all information which could impact Health and Safety,
<br />e.g., power lines, integrity of dikes, terrain, etc.)
<br />PART II
<br />EVALUATION OF POTENTIAL HAZARDS
<br />Chemicals Hazards
<br />B Carcinogens: _
<br />❑ Corrosives:
<br />❑ Dusts:
<br />❑ Explosives:
<br />Flammables: _
<br />❑ Inorganic Gases:
<br />Metals:
<br />❑ Oxidizers:
<br />❑ PCB's:
<br />PART III
<br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT
<br />I . 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 />If monitoring instruments are not used, rationale or activity / area restrictions:
<br />2. Personal Protective Equipment
<br />Level of Protection: ❑ A ❑ B
<br />,;In Hard Hat.
<br />,�g Safety Glasses/goggles.
<br />,® Steel toed/shank shoes or boots.
<br />❑ Flame retardant coveralls.
<br />Jam' Hearing protection.
<br />❑ Tyvek.
<br />❑ Respirator: ❑ APR
<br />A/P cartridge:
<br />Safety vest.
<br />® Two-way communication.
<br />El ❑D
<br />❑ SCBA
<br />PART IV - PLAN APPROVAL
<br />Plan Prepared by: L014 wce; i Date: Vr 30 --VA
<br />Plan Approved by: Date: 30
<br />ENVIRWs'MENTAL HEALTh DEPARTMENT
<br />Pa�,N
<br />SAN JOAQUIN COUNTYUnit
<br />Donna K. Heran, R.E.H.S.
<br />Director 304 East Weber Avenue, Third Floor
<br />Supervisors
<br />Carl Borgman, R.E.H.S.
<br />•'
<br />Al Olsen, R.E.H.S. Stockton, California 95202-2708
<br />Mike Huggins, R.E.H.S., R.D.I.
<br />P
<br />4�/FORS`
<br />Program g ram Mana er
<br />Telephone: (209) 468-3420
<br />Laurie A. Cotulla, R.E.H.S.
<br />Douglas W. Wilson, R.E.H.S.
<br />Margaret Lagorio, R.E.H.S.
<br />Program Manager Fax: (209) 464-0138
<br />Robert McClellon, R.E.H.S.
<br />SITE HEALTH AND SAFETY PLAN
<br />Mark Barcellos, R.E.H.S.
<br />PART
<br />GENERAL SITE INFORMATION
<br />1. Site Name: Na -T 6'r %LA,U,.PV'.
<br />Address: tcJA W. c,T�
<br />Contact Person: etr.) LaoYn Phone No: 240,+Wf, 000
<br />Sweeps Number:
<br />Proposed Date of investigation/inspection: oe -3(:>oc
<br />2. Description and brief narrative of inspection activity:
<br />❑ New UST installation. ❑ UAR Investigation.
<br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair.
<br />❑ Tank/Pipe Removal. ❑ Re -excavation.
<br />❑ Installation of Borings /Monitoring Wells.
<br />�tw trsspEc�c-to�
<br />3. Specific Site Information:
<br />Tank No.:
<br />Tank Capacity:
<br />Tank Content: Tank Age:
<br />Other:
<br />4. Type of Operation: rnAiijTwi' JP41)l.6 R.eIP41 R
<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 and Safety
<br />Physical Concerns: (check all that apply & describe)
<br />❑ Hear or Cold Stress: °F (high ambient temp.)
<br />[Noise Sources:—_s��ttv►.tSt:?T
<br />❑ Oxygen Deficiency:
<br />❑ Excavation: (falls, trips, slipping, cave-ins):
<br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions,
<br />etc..):
<br />❑ Confined space entry: (explosions):
<br />❑ Heavy equipment (physical injury & trauma resulting from moving
<br />equipment):
<br />❑ Other, specify
<br />Anticipated Biological Hazards:
<br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants
<br />❑ Other/Unknown (specify):
<br />8. Irrative (provide all information which could impact Health and Safety,
<br />e.g., power lines, integrity of dikes, terrain, etc.)
<br />PART II
<br />EVALUATION OF POTENTIAL HAZARDS
<br />Chemicals Hazards
<br />B Carcinogens: _
<br />❑ Corrosives:
<br />❑ Dusts:
<br />❑ Explosives:
<br />Flammables: _
<br />❑ Inorganic Gases:
<br />Metals:
<br />❑ Oxidizers:
<br />❑ PCB's:
<br />PART III
<br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT
<br />I . 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 />If monitoring instruments are not used, rationale or activity / area restrictions:
<br />2. Personal Protective Equipment
<br />Level of Protection: ❑ A ❑ B
<br />,;In Hard Hat.
<br />,�g Safety Glasses/goggles.
<br />,® Steel toed/shank shoes or boots.
<br />❑ Flame retardant coveralls.
<br />Jam' Hearing protection.
<br />❑ Tyvek.
<br />❑ Respirator: ❑ APR
<br />A/P cartridge:
<br />Safety vest.
<br />® Two-way communication.
<br />El ❑D
<br />❑ SCBA
<br />PART IV - PLAN APPROVAL
<br />Plan Prepared by: L014 wce; i Date: Vr 30 --VA
<br />Plan Approved by: Date: 30
<br />
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