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P4tu 1 N. <br />ENVIRON ENTAL HEALTH D19ARTMENT <br />Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY <br />•�(jF�'R a`P 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 />JeffCarrttesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: Re e V�t Yt <br />Address: V5 D 5 O E- - �f?Ch ltC <br />Contact Person: JE!� ZCL <br />Phone #: ('�' oo-) q 4'q 'qO(.O <br />Proposed Date of investigation/inspection: "/1 112- <br />2. <br />12 <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 />Y-lklazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <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 />iccavation (falls, trips, slipping, cave-ins): <br />Iandling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />�uipment): <br />eavy equipment (physical injury & trauma resulting from moving <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />❑ Snakes Insects [3 Rodents El 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 (12/16/2011) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards n <br />carcinogens: t�h 1 _ e/� GXJ <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />C(lammables:"-'Q 4 0 Yn� ' <br />Inorganic Gases: <br />❑ Metals: <br />V Oxidizers: Q-A& OLS I'] <br />❑ PCBs: <br />`Other: "ZP�t% <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 ❑ C ® D <br />�j 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 />Z Safety vest <br />19iwo-way communication <br />❑ Other (specify): <br />❑ SCBA <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared"My, Date: 2� <br />Plan Approved by: 1\V 1 Date I <br />