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Pqu rry <br />z z ENVIRO ENTAL HEALTH D ARTMENT <br />• �q��FORN`P SAN JOAQUIN COUNTY Program Coordinators <br />Donna K. Heran, R.E.H.S. <br />Director 600 East Main Street, Stockton, California 95202 Kase Y 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 <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE <br />1. Site Name: <br />Contact Person: _ A4& AlD I G S <br />Phone #: 4&(' <br />Proposed Date of investigation/inspection: (li <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 />Pampling C1Boring / Monitoring Well installation <br />azardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />, <br />4. Type of Operation: AL& U <br />5. Release History <br />Evidence of leaks / soil contamination: VVES ❑ NO <br />Documented Groundwater contamination: j® YES ❑ NO <br />Backgr and descri tion of any previo vest'ation 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 />❑ Excavation (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />❑ Other (specify): <br />7. Anticipated Biological Hazard?: <br />❑ Snakes InsectsRodents ElPoisonous Plants <br />ElOther/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 (6/23/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />Carcinogens: <br />'Corrosives: <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 />❑ 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 />® 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 />❑ Two-way communication <br />❑ Other (specify): <br />PART IV <br />PLAN APPROV E <br />Prepb <br />Plan P ared : " �/��M�" 1✓I �W Date: �� 1 <br />Y <br />Plan Approved by: + Date: `o' I'L'O <br />