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ENVIRONMENTAL HEALTH LEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna IG Heran,R.E.H.S. Unit Supervisors <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> AI Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> • °tJ ....,Nx: Program Managerele hone: 209 468-3420 Douglas W.Wilsgn,R.E.H.S. <br /> T <br /> Foe Laurie A.Cotulla,R.E.H.S. P ( ) Margaret agon ,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert et <br /> SITE HEALTH AND SAFETY PLAN Mark Barcellos,R.E.H.S. <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name:San Joaaum River Club 1. Chemicals Hazards <br /> Address:30000 Kasson Road.Tracy.CA 95376 ®Carcinogens: <br /> Contact Person:Jerry Cutter Phone No:(209)602-7038 ❑Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection:February 19.2004 ❑Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. <br /> ®Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ®Hazardous Waste Inspection ❑Sampling. PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of operation:Maintenance ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C OD <br /> ®Hard Hat. <br /> 6. Potential Health and Safety ®Safety Glasses/goggles. <br /> Physical Concerns:(check all that apply&describe) ®Steel toed/shank shoes or boots. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> ®Noise Sources: EOUB'MENT ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator: El APR ❑SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ,z <br /> Plan Prepared by Date:2 4 d <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants � / <br /> ElOther/Unknown(specify): Plan Approved by: llJ.a_/ <br /> Dale: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.):UNKNOWN <br /> EH 23081(12117/2002) <br />