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qu1N <br />EN"ROAENTAL HEALTH DIIPARTMENT <br />cq(/FOPijIP• SAN JOAQUIN COUNTY program Coordinators <br />Donna K. Herao, 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/chd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE <br />t. Site Name: <br />Contact <br />Proposed Date of <br />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 />El Sampling ❑ Boring / Monitoring Well installation <br />'150azardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank Capacity: <br />Tank Content: <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 />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 />;gjHaradling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />❑ Confined space entry (explosions): <br />aqcavy equipment (physical injury & trauma resulting from moving <br />uipment): <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />,Mnakes >,lnsects XRodeots ❑ 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 (3/5/2012) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />-JCarcinogens: /917 <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />[�'lammables• �I � � � ��e <br />Inorganic Cranes: <br />❑ Metals: <br />00xidizeus: acL49&11 <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 />CRNone (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 <br />E Hard Hat <br />N Safety Glasses/Goggles <br />E Steel toed/shank shoes or boots <br />❑ Flame retardant coveralls <br />E Hearing protection <br />❑ Tyvek <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P Cartridge: <br />E Safety vest �/� <br />�.vo-way communicatiollr t J <br />❑ Other (specify): <br />011 E0 9 <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared : — Date: <br />Plan Approved by: Date: I I <br />