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)QpN�;N•.•pq <br />a: .< <br />EwiRAIENTAL HEALTH AARTMENT <br />Donna K. Heraa, R.E.H.S. SAN JOAQM COUNTYProgram Coordinators <br />Director 600 East Main Street, Stockton, California 95202 ICssey L. Foley, R.E.H.S. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, R.E.H.S. <br />JeffCamtesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE <br />1. Site Name: <br />Contact F <br />Phone #:_ <br />Proposed <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ UAR Investigation <br />❑ Tank Closure in Place <br />❑ TanktPipe Repair <br />❑ Tank/Pipe Removal <br />❑ Re -excavation <br />❑ Sampling <br />❑ Boring / Monitoring Well installation <br />]� Hazardous Waste inspection <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: <br />Tank Age: <br />4. Type of Operation: W 4:6 ) 'f7 / (/_Y I.('j <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: <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 />equipment): <br />❑ Other(specify): <br />Anticipated Biioollogical Hazards: <br />`Snakes til Insects ❑ Rodents ElPoisonous Plants <br />❑ Odter/Unlatown (specify): <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />Carcinogens: <br />❑ Corrosives: <br />P) Dusts: <br />1�LExplosives: <br />E�.Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />❑ Other. <br />PART HI <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 />® Safety vest <br />❑ Two-way communication <br />❑ <br />Other (specify): <br />PART IV <br />PLAN APPROVAL <br />8. Narrative (provide all information which could impact Health and Safety, Plan Prepared by: M N � 1ti Date: -24-2 3 t <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Approved by: (, Date , <br />EH 23081 (2/23/2011) <br />