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P(;U IIy ENVIRONMENTAL HEALTH DEPARTMENT • c��iFo'a`i�' • Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. Telephone: (209) 468-3420 Fax. (209) 468-3433 Robert McClellon, R.E.H.S. Web: www.sjgov.org/ehd Jeff Carruesco, R.E.H.S. SITE HEALTH & SAFETY PLAN PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS Site Name: Address: Contact Person: Phone #: Sao ` .a12 x Proposed Date of investigationhnspection: /1 Lf 2. 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 _kHazardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: uAku /to -- 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 & Safetry Physical Concerns: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: # I 101-4 vi/VaC W i IV— ❑ 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 in' & trauma resulting from moving equipment):` 1 rS El Other (specify): 8. Chemicals Hazards Ca-Carcinogens:lh p; I ❑ Corrosives: Dusts: ❑ Explosives: ,UFlammables: ❑ Inorganic Gases: r -P j! PAAD, , t.' 2 -metals: ❑ Oxidizers: ❑ 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 ® 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): Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants PART IV ❑ Other/Unknown (specify): PLAN APPROVAL Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (8/6/2010) ❑ SCBA Plan Prepared by: Date: 04-2,6-/t Plan Approved by: Date: