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app"' � �`• c <br />Z ENIVIRONIMENTAL HEALTH AeARTMENT <br /><<Fosa Donna K. Haran, 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 />Jeff Carruesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFO ATI <br />1. Site Name: <br />Address: <br />Contact Person: <br />Phone #: <br />Proposed Date of investigation/inspection: <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 />❑ Sampling ❑ Boring / Monitoring Well installation <br />Hazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank <br />4. Type of Operation: <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 />%Excavation (falls, trips, slipping, cave-ins): <br />'Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />❑ Confined space entry (explosions): <br />Meavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />Snakes 14ihrsects 1-d Rodents ❑ 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 (2/7/2011) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />Carcinogens: <br />Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />❑ Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />❑ Other: <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 />,KNone (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 <br />A/P Cartridge: <br />❑ SCBA <br />® Safety vest /� <br />*Two-way communication Qhoya— <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared Date: / l <br />Plan Approved by: 4V u f" Date: <br />