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O.P4u 1N'. <br />y: ENVIRONOIENTAL HEALTH DOPARTMENT <br />• CqC/i..... . SAN JOAQUIN COUNTY Program Coordinators <br />Donna K. Heran, R.E.H.S. Kase L. Fol R.E.H.S. <br />Director 600 East Main Street, Stockton, California 95202 Y Foley, <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Robert McClellon, R.E.H.S. <br />J <br />Web: www.sjgov.org/ehd effCarruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ UAR Investigation <br />❑ Tank Closure in Place <br />❑ Tank/Pipe Repair <br />❑ Tank/Pipe Removal <br />❑ Re -excavation <br />❑ Sampling <br />❑ Boring / Monitoring Well installation <br />/` &azardous Waste inspection <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: <br />Tank Age: <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />V <br />icals Hazards <br />arcinogens: <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 />// d ❑Detector Tubes (specify): <br />4. Type of Operation: /Ll/,(%/% ��/7� ❑ Photo ionization Detector <br />❑ Or anic Va or Anal zer <br />5. Release History: <br />Evidence of leaks / soil contamination: [I YES El NO <br />Documented Groundwater contamination: ❑ YES [I 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 />oise Sources: <br />Oxygen Deficiency: <br />Excavation (falls, trips, slipping, cave-ins): <br />andling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />❑ Confined space entry (explosions): <br />eavy equipment (physical injury & trauma resulting from moving <br />-equipment): <br />❑ Other (specify): <br />7. )Anticipated )Biole <br />ical Hazards: <br />Snakes sectsnts Poisonous Plants <br />WOtherlUnknown (specify El <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 (4/7/2010) <br />g p y <br />❑ Other (specify): <br />txone (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 />;'wo-way communication tob07z.Q_ <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared b Date: <br />Plan Approved by: Date: <br />