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so,Rri1V1N. <br />t.' �Q.cgry <br />ENVIRO#&NTAL HEALTH APARTMENT <br />SAN JOAQUIN COUNTY <br />crrtdnN <br />Donna K Heran, R.E.H.S. Prograut 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 />Jeff Carruesco, R.E.H.S.Web: www.sjgov.org/ehd <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name:/�j�rD <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 <br />Wells <br />71Haz mlous waste inspection <br />❑ Sampling <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: RL Tank Capacity:��� <br />Tank Content: WykA Tank Age: <br />4. Type of Operation: U-1 VM <br />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: OF (high ambient temp.) <br />g 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 />0 Heavy equipment (physical injury & trauma resulting from moving <br />❑ Other <br />7. ,pLnticipatod Biological Hazards: <br />JRJ Snakes hrsects V Rodents ❑ Poisonous Plants <br />❑ <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 (3/92010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />XFlammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (Note: Monitoring instruments most 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 />AT cartridee: <br />® Safety vest <br />❑ Two-way communication <br />❑ Other (specify): <br />PARTIV-PL APPROVAL P YI <br />q /I�/J� <br />Plan Prepared by: Date: <br />Plan Approved by: Date: <br />