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a!'`�ulM• c <br />ENVIRONl ENTAL HEALTH D ARTMENT <br />SAN JOAQUIN COUNTY <br />Donna K. Neran, R,E.H.S. Program Coordinators <br />Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R. E. H.S. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/ehd Jeff Carruesco, R.E.H.S. <br />Linda Turkatte, R.E.H. S. <br />PART <br />GENERAL SITE LN -FORMATION <br />1. Site Name: ` \ ! /�]/l, r I t <br />Address: --1600 ✓'. .� 'r7i <br />Contact Person: <br />Phone#: —10 <br />Proposed Date of investigation/inspection:- <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ Tank Closure in Place <br />El Tank/Pipe Removal <br />❑ Sampling <br />Hazardous Waste inspection <br />SITE HEALTH & SAFETY PLAN <br />❑ UAR Investigation <br />❑ Tank/Pipe Repair <br />❑ Re -excavation <br />Q Boring / Monitoring Well installation <br />Q Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content; Tank Age:- <br />4. <br />ger <br />4. Type of Operation: <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 />OOise Sources: <br />xygen 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 />equipment (physical injury & trauma resulting from moving <br />%:Pzy <br />ent): <br />❑ Other (specify): <br />7. Anticipated Biological Hazar s: <br />Snakes Insects dents ❑ 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 23091 (8/11/2011) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />Carcinogens:_ 1, <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />X'Hammables: <br />Inorganic Gases: r5u on <br />❑ Metals: <br />MOxidizcrs: <br />❑ PCBs: <br />O11 � <br />ether: thio U0 VbYI'L iyutrt.it_a <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 />Nonc (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 0 D <br />Z 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 />[[Two-way communication <br />❑ Other (specify): <br />PkDvcel <br />PART IV <br />PLAN APPROVAL <br />Plan Preparedrb� Date: <br />Plan Approved by: �f �! Date: (("'i'( <br />