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z ENVIROAENTAL HEALTH D*ARTMENT <br />c4�IFOR��r <br />Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY 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) 464-0138 Robert McClellon, R.E.H.S. <br />J <br />Web: www.sjgov.org/ehd effCarruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATIONv� � ��r <br />1. Site Name: -For u <br />Address: <br />Contact Person: Phone qMy <br />Proposed Date of investigation/inspectiowfill <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ UAR Investigation <br />❑ Tank Closure in Place <br />❑ Tank/Pipe Repair <br />❑ Tank/Pipe Removal <br />❑ Re -excavation <br />❑ Installation of Borings / Monitoring Wells <br />Kazardous waste inspection <br />❑ Sampling <br />❑ 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 />fPo tial Health & Safety P 1 Concerns: (,/all that apply & describe) <br />Heat or Cold Stress: —lL—°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, <br />❑ Confined space entry (explosions): <br />Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipatedjolo ical H d . <br />Snakes sects Rodents E] Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.) <br />EH 23081 (3/9/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />arcmogens: <br />Corrosives: <br />Dusts: <br />❑ Explosives: <br />'Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />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 <br />,®,_, Safety vest <br />1POwo-way communication <br />(/((("`❑�I Other (specify): <br />PART IV - PL IPPR V <br />6 1l, <br />Plan Prepared by: Date: <br />Plan Approved by:Date: !/ <br />