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pqu r!y z. 3 ENVIROAIENTAL HEALTH D ARTMENT SAN JOAQUIN COUNTY Program Coordinators Donna K. Heron, R.E.H,S. Director 600 East Main Street, Stockton, California 95202 Rase Y L. Fole Y, R.E.H.S. Telephone: (209) 468-3420 Fax. (209) 464-0138 Robert McClellan, RE.H.S. Web: www.sjgov.org/ehd Jeff Carruesco, R-E.H.S. SITE HEALTH & SAFETY PLAN PART GENERAL SITE I TIO 1. Site Name: Address: Contact Person: Ph ne # Proposed Date of investigation/inspection: Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Tank/Pipe Removal ❑ Re -excavation ❑ Installation of Borings / Monitoring Wells Hazardous waste inspection ❑ Sampling Tiered Permitting inspection �A x 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: ��✓ _ Release History: Evidence of leaks / soil contamination: ❑ YES IO Documented Groundwater contamination: ❑ YES P'NO Background and description of any previous investigation or incidence: Potential Health & Safety Physical Concerns: (✓ all that apply & describe) 7 Heat or Cold Stress: (10b °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: KSnakes XInsects Rodents ❑PoisonousPlants 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 (3/4/2010) PART II EVALUATION OF POTENTIAL HAZARDS fal-sm cats Hazards rcinogens: rrosives: Explosives: Flammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCBs: 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): one (see below) If monitoring instruments are not used, rationale or activity/area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ❑ 1) Z Hard Hat ❑ Safety Glasses/Goggles Steel toed/shank shoes or boots Flame retardant coveralls ® Hearing protection ❑ Tyvek C] Respirator: ❑ APR ❑ SCBA A/Pcamidge: � Safety vest Two-way communication ❑ Other (specify): ff PART IV -PLAN APPRC) J i of Plan Prepared by: Date: Plan Approved by: V Date: