Laserfiche WebLink
pg4!N <br />Q: <br />ENVIROAENTAL HEALTH DOPARTMENT <br />SAN JOAQUIN COUNTY Program Coordinators <br />,trFORa Donna K. Heran, R.E.H.S. <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 />Jeff Carruesco, R.E.H.S. <br />Web: www.sjgov.org/ehd <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFO TIQN / <br />L Site Name: wC/ <br />Address: <br />Contact Person: 61d Phone #1J 7 36 <br />Proposed Date of investigation/inspection: <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 />�L❑ <br />Til Hazardous waste inspection <br />//El <br />❑ Sampling <br />Tiered Permitting inspection <br />3. Specific Site Information <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: CC 4.Type of Operation:)) ..J mLatlh— �( <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 />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, <br />❑ Confined space entry (explosions): <br />Heavy equip t (p sical inj�y & trauma resulting from moving <br />equipment): � (.� Lir , <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />1P Snakes ff Insects Rodents ❑ 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 />Carcinogens:_ <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 />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 El 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 cartridee: <br />® Safety vest <br />Two-way communication <br />Other (specify): <br />ThM <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: Date: 4 <br />Plan Approved by: j'/ Dater` <br />