Laserfiche WebLink
ENVIRONMENTAL HEALTHDEPARTMENT <br /> ' PqulN..Cp SAN JOAQUIN COUNTY <br /> e .t Donna YL Heran,RE.H.S. Unit Supervisors <br /> Director304 Hast Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> .'a•. P• <br /> Program Manager Douglas W.Wilson,R.E.H.S. <br /> 4�lot:�v Laurie A.Cotulla,R.E.H.S. Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION / EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: �!^�G A� zt4l-f- I. Chemicals Hazards <br /> Address: a s(5 N W e 1�k"4 Ww <br /> Carcinogens: <br /> Contact Person: Phone No: 2torrosives: <br /> Sweeps Number: <br /> ❑Dusts' <br /> Proposed Date of investigation/inspection: <br /> ❑Explosives: <br /> 011ammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> ' w ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: i+fh� l It�;+v� ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑ YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C <br /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ,❑Safety Glasses/goggles. <br /> El Noise Sources: EJ Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ElExcavation:(falls,trips,slipping„cave-ins): [_1 Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑ Insects ❑Rodents ❑Poisonous Plants 7,e7/ <br /> Plan Prepared by: Date: JT <br /> ❑Other/Unknown(specify): 7 <br /> Plan Approved by: Date: .7 0 <br /> S. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />