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PqurN <br />CqC%FpRa`P <br />ENVIRQNMENTAL HEALTH DPPARTMENT <br />Donna K. Heran, <br />Director <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: D, 9-2S > F�, <br />Contact Person: X1(1 a to FP5 <br />Phone #: l20 — -7 <br />Proposed Date of investigation/inspec <br />2. Description and brief narrative of ins <br />❑ New UST installation ❑ <br />❑ Tank Closure in Place ❑ <br />❑ Tank/Pipe Removal ❑ <br />❑ Sampling ❑ <br />"Hazardous Waste inspection ❑ <br />3 <br />Specific Site Information: <br />Tank No.: <br />Tank Content: <br />Other: <br />4. Type <br />5. Release History: <br />Evidence of leaks / soil contamination: <br />Documented Groundwater contaminati <br />Background and description of any pre <br />6. Potential Health & Safety Physical Cor <br />❑ Heat or Cold Stress: °F <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />Excavation (faM, trips, slipping, ca <br />Handling and Transfer of a Hazard( <br />❑ Confined space entry (explosions):_ <br />❑ Heavy equipment (physical injury & <br />❑ Other <br />7. Anticipatediological Hazards: <br />❑ Snakes hrsects 1< Rodents <br />❑ Other/Unknown (specify): <br />SAN JOAQUIN COUNTY program Coordinators <br />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 />n activity: <br />Investigation <br />Pipe Repair <br />/ Monitoring Well installation <br />Permitting inspection <br />Capacity: <br />❑ YES ❑ NO <br />❑ YES ❑ NO <br />investigation or incidence: <br />(✓ all that apply & describe) <br />ambient temp.) <br />Substance (fire, explosions, etc.): <br />trauma resulting from moving <br />❑ Poisonous Plants <br />8. Narrative (provide all information which]could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terra, etc.): <br />EH 23081 (8/11/2011) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />Corrosives: Ko N, s 6 ,�1. tiu�ao�� ion � . j�tyo / <br />❑ Dusts: <br />❑ Explosives: <br />�9171ammables: 62llD&rZ. PO -40 <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 />None (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 <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 ❑ SCBA <br />A/P Cartridge: <br />® Safety vest <br />"OT -0 -way communication 191 an-' <br />❑ Other (specify): <br />FE19NEWE <br />PART IV <br />PLAN APPROVAL <br />' <br />Plan Prepared <br />Date: <br />Plan Approved by:�U \ <br />Date: I <br />