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ENVIRONMENTAL HEALTH DEPARTMENT Donna K. Haran, R.E.H.S. SAN JOAQUIN COUNTY program Coordinators Director 600 East Main Street, Stockton, California 95202 Kaley L. Foley, RE.H.S. Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, RE.H.S. Web: www.sjgov.org/ehd Jeff Carruesco, R.E.H.S. SUE HEALTH & SAFETY PLAN PART GENERAL SITE INFORMATION no., WIN a WA ONE VISEE Evil KILIME a. IJ tI RINIIS t i! t Proposed Date of investigation/iospection Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ TankTipe Removal ❑ Re -excavation ❑ Sampling ❑ Boring / Monitoring Well installation VElez�ar�dous,Waste inspection ❑Tiered Permitting inspection 3. Specific S� i�lot'mtion: Tank No.: Tank Capacity: Tank Content: Tank Age: 4. Type of Operation: A1441 O#eAN , 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: Potential Health & SafeV Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: 'F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): ❑ Heavy equipment (physical injury &trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ OthafUnlmown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (8/6/2010) PART II EVALUATION OFPOTEN�TIALHAZARPS I. Chemicals Hazards TGUNw'� (ij,0�fL61� ❑ Carcinogens: IAD, tri ❑ Corrosives: ❑ Dusts: ❑ Explosives: ❑ Flammables: ❑ Inorganic Gases:fQ-,r ❑ Metals: u ❑ Oxidizers: ❑ PCBs: ❑ Other M of � i nx%r�¢. e2ogPM ({uA� PART III W—r COPDLI. k K PwIMIBI b 1CS4iUlhal� REQUIRED PERSONAL PROTECTIVE EQUIPMENT I. Monitoring Equipment (Note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided): ❑ Combustible Gas/Oxygen Meter ❑ Detector Tubes (specify): ❑ Photo ionization Detector ❑ Organic Vapor Analyzer ❑ Other(specify): ❑ None (see below) If monitoring instruments are not used, rationale or activity/area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat ® Safety Glasses/Goggles ® Steel toed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR A/P Cartridge: ® Safety vest ❑ Two-way communication ❑ Other (specify): PART IV PLAN APPROVAL ❑ SCBA Plan Prepared by: Date: 3 I / Plan Approved by: Date: