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Pqu1H <br />ENVIRON 1./IENTAL HEALTH f&ARTMENT <br />a: Z< <br />• c;�/Foai'�' • SAN JOAQUIN COUNTY Program Coordinators <br />Donna K. Heran, R.E.H.S. <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 I <br />GENERAL SITE I,N5.ORM./A�TIION <br />1. Site Name: 'd 2 i <br />Contact Person: I <br />Phone #7 011 <br />Proposed Date of investigation/in! <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 />Specific Site Information: <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />gFlammables: �-.'J L) Iye'-.7 <br />❑ Inorganic Gases: <br />❑ Metals: <br />-X Oxidizers: 0)< 46441 <br />❑ PCBs: <br />❑ Other: Al'�O Or'OCi�IOr (j fz�x��/ <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank No.: Tank Capacity: <br />I . Monitoring Equipment (Note: Monitoring instruments must be used for all <br />Tank Content: Tank Age: <br />operations unless appropriate rationale or restrictions are provided): <br />Other: <br />❑ Combustible Gas/Oxygen Meter <br />❑ Detector Tubes (specify): <br />L �� �,, /� <br />Type of Operation:PO1 <br />Photo ionization Detector <br />❑ Organic Vapor Analyzer <br />Release History: <br />❑ Other (specify): <br />Evidence of leaks / soil contamination: ❑ YES <br />❑ NO <br />None (see below) <br />Documented Groundwater contamination: ❑ YES <br />❑ NO <br />If monitoring instruments are not used, rationale or activity/area restrictions: <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: OF (high ambient temp.) <br />Noise Sources: <br />/❑ Oxygen Deficiency: <br />i Excavation (falls, trips, slipping, cave-ins): <br />Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />XHeavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />Snakes 'Insects Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (9/15/2010) <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 />J'Two-way communication <br />❑ Other (specify): <br />[■�►5C <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared bDate: <br />Plan Approved by: vp, Date: 1 <br />