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ENVIRONi'v'IENTAL HEALTH DgARTMENT Donna K. Heran, R. Director PART GENERAL SITE INFORMATION 1. Site Name: LkA ovyl Pan Contact Person:— Phone #: Proposed Date of 2. Description and brief narrative of ❑ New UST installation ❑ ❑ Tank Closure in Place ❑ ❑ Tank/Pipe Removal ❑ ❑ Sampling ❑ Hazardous Waste inspection ❑ 3. Specific Site Information: Tank No.: Tank Content: 4. Type of 5. Release History: Evidence of leaks / soil contaminat Documented Groundwater contami Background and description of any 6. Potential Health & Safety Physical ❑ Heat or Cold Stress: ❑ Noise Sources: ❑ Oxygen Deficiency: xcavation (falls, trips, slipping, andling and Transfer of a Haza ❑ Confined space entry (explosions) VHeavy equipment (physical injury eaminment): ❑ Other 7. Anticipated Biological Hazards: snakes Insects 'g] [n OOther/U own (specify): - 8. Narrative (provide all information i e.g., power lines, integrity of dikes, EH 23081 (8/11/2011) SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd SITE HEALTH & SAFETY PLAN n activity: Investigation Pipe Repair / Monitoring Well installation Permitting inspection Capacity: ❑ YES ❑ NO ❑ YES ❑ NO investigation or incidence: (✓ all that apply & describe) (high ambient temp.) Substance (fire, explosions, etc.): trauma resulting from moving ❑ Poisonous Plants could impact Health and Safety, n, etc.): Prograur Coordinators Kasey L. Foley, R.E.H.S. Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. Linda Turkatte, R.E.H.S. PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards Carcinogens: , / Corrosives: "ria ll 'r -1 , Net d l7 ❑ Dusts: ❑ Explosives: F lammables/4C v l ❑ Inorganic Gases: L2dD�11ZQ ❑ Metals: EJ Oxidizers:8(%M ❑ PCBs: a Other A/ t L w . t4,b PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (Note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided): ❑ Combustible Gas/Oxygen Meter ❑ Detector Tubes (specify): ❑ Photo ionization Detector ❑ Organic Vapor Analyzer ❑ Other (specify): bl%1one (see below) If monitoring instruments are not used, rationale or activity/area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat ® Safety Glasses/Goggles ® Steel toed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR A/P Cartridge: ® Safety vest EXTwo-way communication ❑ Other (specify): ❑ SCBA P�q mf-_ PART IV PLAN APPROVAL Plan Prepared by: ate: Plan Approved by: Date: