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o.Pqu rN•..e ENVIRONMENTAL HEALTH DEPARTMENT �f FO•a� Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators Director 1868 E. Hazelton Ave., Stockton, California 95205 Kasey L. Foley, R.E.H.S. Telephone. (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. SITE HEALTH & SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: Address:i Contact Person: Phone #: Proposed Date of investigation/inspection: 0 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 10azardous Waste inspection ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: 4. Type of Operation 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: ❑ 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 ❑ Other (specify): Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (7/13/2012) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards 6arcinogens:_ ❑ Corrosives:_ ❑ Dusts: ❑ Explosives: ❑ Flammables: ❑ Inorganic Gases: Metals: NA$�L,Q� � XLQ ElOxidizers: ❑ 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 ❑ SCBA A/P Cartridge: ® Safety vest ❑ Two-way communication ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepared by: AJ 'I�iDate . Plan Approved by: Date: