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ao44�S oo . 2, z ENVIRON*ENTAL HEALTH DRARTMENT :FOR�PSAN JOAQUIN COUNTY Program Coordinators Direectorctor Donna K. H R.E.H.S. 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. Telephone: (209) 468-3420 Fa. - x(209)468-3433 Robert McClellon, R.E.H.S. Jeff Catruesco, R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte,R.E.H.S. SITE HEALTH & SAFETY PLAN PART GENERAL SITE Phone #: Proposed Date Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Tank/Pipe Removal ❑ Re -excavation ❑ Sampling ❑ Boring/ Monitoring Well installation TP azardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank Capacity: Tank Content: Tank 4. Type of Operation 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health & Safety 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 & tmuma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (6/142012) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards ,L Carcinogens: ti( l—rte P) ❑ Corrosives: ❑ Dusts: ❑ Explosives: .j�Flammables �A-!B �DA)Ul ❑ Inorganic Gase : ❑ Metals ❑ Oxidiz ❑ PCBs:. ❑ Other: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. 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 E D ® Hard Hat N Safety Glasses/Goggles N Steel toed/shank shoes or boots ❑ Flame retardant coveralls ® Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR ❑ SCBA A/P Cartrii N Safety vest ❑ Two-way communication ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepared by: ate: Plan Approved by: _ U Date: