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raq.4a�.coi <br />a ENVIRON�NTAL HEALTH APARTMENT <br />Donna K. Heron, R.E.H.S. SAN JOAQUIN COUNTY 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 />s ov.or ehd <br />Jeff Canuesco, R.E.H.S. <br />Web: www <br />Jg Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: / <br />Address: '3c, -7-7)r 1-'r,s...n r LG...ti <br />Contact Person:_(1,0�.. <br />Phone#: �76� 1930 <br />Proposed Date of investigation/inspection: 6 1 9i 11 1 <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 />❑ Sampling <br />❑ Boring / Monitoring Well installation <br />,,—E3:9azardous Waste inspection <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank <br />Tank <br />Tank Content: Tank Age: <br />4. Type of Operation: Ati / 412AIl.- <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 />❑ 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 />❑ Other <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ 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 (6222011) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />❑ Flammables: <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 />❑ 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 hoots <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 />PART IV <br />PLAN APPR1jOVVAAAL <br />Plan Prepued`� Date: <br />Plan Approved y: 2U� Date: 1 ` <br />