COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

O.p4u1N C ENVIRONMENTAL HEALTH D PARTMENT /PCR�`P SAN JOAQUIN COUNTY Program Coordinators Donna K. Heran, R.E.H.S. 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 GENERAL SITE INFORMATION 1. Site Name: f /f1',[o' llda-1 Address: ~% d Contact Person: Phone #: D c! Proposed Date of investigation/inspection: 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 Hazardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: ,,� w t� ` , 4. Type of Operation: VqQU l� � a � c 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: f5L0aEJ13.A ❑ Oxygen Deficiency: ❑ Excavation (falls, trips, slipping, cave-ins): Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. ❑ Confined space entry (explosions): Heavy equipme (physical injury & trauma resulting from moving equipment): G►'ti( ❑ 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 (4/7/2010) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards *arcinogens: ❑ Corrosives: Dusts: ❑ Explosives: )dylammables: ❑ Inorganic Gases: `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): one (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: ❑ SCBA Safety vest Two-way communication f kvx-(L, ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepared Date. Plan Approved by: Date: