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U" if � .co e041ALTH DWARTMET ENTAL HEN a. :< SJ A COUNTY Program Coordinators Donna K. Henan, R.E.H.S. Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. PART GENERAL SITE INFORMATIO 1. Site Name% Contact Person: i Phone #: �9q Proposed Date of investigation/im 2. Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Tank/Pipe Removal ❑ Re -excavation ❑ Sampling ❑ Boring / Monitoring Well installation Hazardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) 19 Noise Sources: ❑ Oxygen Deficiency: 1p Excavation (falls, trips, slipping, cave-ins): 19 Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. ❑ Confined space entry (explosions): FHeavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards Carcinogens: Corrosives: R Dusts: (� Explosives: Flammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCBs: ❑ Other: 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): ❑ None (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 ❑ Two-way communication ❑ Other (specify): 7. Anticipated Biological Hazards: Snakes ff Insects '59 Rodents ❑ Poisonous Plants PART IV ❑ Other/Unknown (specify): PLAN APPROVAL ❑ SCBA 8. Narrative (provide all information which could impact Health and Safety, Plan Prepared by: M Naidu Date: 1'2 e.g., power lines, integrity of dikes, terrain, etc.): Plan Approved by: Qu�Date: � Z EH 23081 (5/6/2011)