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PQU I ly <br />Z ENVIRONMENTAL HEALTH DEPARTMENT <br />cq�;FaRN: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 <br />GENERAL <br />1. Site Na <br />Contact Person: <br />Phone #: DO <br />Proposed Date of investigation/inspection: <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 />❑ Sampling ❑ Boring / Monitoring Well installation <br />,Hazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <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 />6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />Noise Sources: 4�(�� <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 />KHeavy equipmeggt(t�pphysi�yal injury & trauma resulting from moving <br />equipment): rg-c?" n <br />❑ Other (specify): <br />7. Anticipated Biological Hazar s: <br />El Snakes Insects Rodents ❑ Poisonous Plants <br />❑ Other/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 (4/7/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />carcinogens: <br />❑ Corrosives: <br />xplosives: <br />lammables: <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 />)I 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 />R�Two-way communication owne—) <br />❑ Other (specify): <br />PART W <br />PLAN APPROVAL <br />Plan Prepared Q Date: <br />Plan Approved by: Vim` Date: •��•l4 <br />