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gtlt rN <br />'a �A ENVI 044ENTAL HEALTIMEPARTMENT <br />SAN JOAQUIN COUNTY <br />��' •.....• ��� Donna K. Heran, .E.H.S.Program Coordinators <br />°* Director 304 East Weber Avenue, Third Floor Carl Borgman, R.E.H.S. <br />Laurie A. Cotulla,R.E.H.S. Stockton, California 95202 Mike Huggins, R.E.H.S., R.D.I. <br />Assistant Director Telephone: (209) 468-3420 Kasey L. Foley, R.E.H.S. <br />Margaret Lagorio, R.E.H.S. <br />Fax: (209) 464-0138 Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/ehd Jeff Carruesco, R.E.H.S. <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: At <br />Address: <br />Contact Person: <br />Sweeps Number: <br />Proposed Date of investigatiory <br />No: <br />SITE HEALTH & SAFETY PLAN <br />2. Description and brief narrative of ins ection activity: <br />❑ New UST installation.. ❑ AR Investigation. <br />❑ Tank Closure in Place.. ❑ ank/Pipe Repair. <br />❑ Tank/Pipe Removal. ❑ llte-excavation. <br />❑ htstallation of Borings/ MonitoriWells. <br />�Hazardous waste inspection ❑ ampling �"�t+ <br />] Tiered Permitting inspection <br />3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank No.: �ank Capacity: 1. 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 T b— (S <br />Tu <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />tCarcinogens: <br />❑ Corrosives: <br />Q Dusts: <br />❑ Explosives: <br />Flammables: <br />t] Inorganic Gases: <br />A Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />4. Type of Operation: Used oil Collection center/auto parts store <br />5. Release History: <br />Evidence of leaks / soil cogtaminationj ❑ YES © NO <br />Documented Groundwatercin <br />ontamat n: ❑ YES �] NO <br />Background and description of any preivious investigation or incidence: <br />6. <br />pecrfy). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />T- Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B <br />Potential Health and Safet ® Hard Hat. <br />Physical Concerns: (check l that apply & describe) ® Safety Glasses/goggles. <br />❑ Heat or Cold Stress: (high ambient temp.) ® Steel toed/shank shoes or boots. <br />❑ Noise Sources: <br />❑ Flame retardant coveralls. <br />❑ Oxygen Deficiency: Mng protection. <br />Tyvek. <br />❑ Excavation: (falls, trips, slipping, c ve-ins): <br />Respirator: ❑ APR <br />❑ Handling and Transfer f a Hazard us Substance: (fire, explosions, <br />etc..): L A/P cartridge: <br />❑ Confined space entry: (4plosions <br />❑ Heavy equipment (physijcal injury <br />equipment): <br />❑ Other, specify: <br />7. Anticipated Biological Hazards: <br />❑ Snakes 0 Insects Al Roc <br />❑ Other/Unknown (specif : _ <br />8. Narrative (provide all information <br />e.g., power lines, integrity of dikes, <br />EH 23081 (02/19/03) <br />trauma resulting from moving <br />❑ Poisonous Plants <br />could impact Health and Safety, <br />n, etc.) <br />Safety vest. <br />Two-way communication. <br />* :- <br />❑ SCBA <br />IV - PLAN APPROVAL <br />Plan Prepared by: Michelle Henry Date: January 24, 2011 <br />Ptan Approved by: U Date: <br />