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f <br />ENVIRON 1*IENTAL HEALTH D ARTMENT <br />SAN JOAQUIN COUNTY <br />Donna K. Heran, R.E.H.S. 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) 464-0138 Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S.Web: www.sjgov.org/ehd <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE OION j <br />d <br />1. Site Name: 01M 0 <br />Address: 5 <br />Contact Person. Ph oi a #: <br />Proposed Date of investigation/inspection: 3 <br />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 />[I Installation of Borings / Monitoring Wells <br />NgrlII�azardous waste inspection <br />❑ Sampling <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />4. Type of Operation:— <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 />6.tial Health & Safety Physic 1 Concerns: (,/all that apply & describe) <br />Heat or Cold Stress: OF (high ambient temp.) <br />oise Sources: <br />Oxygen Deficiency: U� <br />Excavation: (falls, tripslldivv ' cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc.): <br />❑ Confined space entry (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipated Biological H ds: <br />makes Insects odents ❑ Poisonous Plants <br />❑ Other/Unlmown (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 (3/9/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />e'cals Hazards <br />arcinogens:orrosives: <br />ts: <br />❑ Explosives: <br />%Flammables: <br />Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <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 boots <br />❑ Flame retardant coveralls <br />® Hearing protection <br />❑ Tyvek <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />Safety vest kq <br />Two-way communication <br />❑ Other (specify): <br />PART IV - PLAN APPR V <br />A/* <br />6� <br />Plan Prepared by: Date: <br />Plan Approved by: V Date: b 1 t(4 1 f l <br />