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ipENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY Program Coordinators Donna K. Haran, R.E.H.S. SAN East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S, Director Telephone: (209) 468-3420 Fax: (209) 468-3433 Robert McClellon, RE.H.S. Web: www.sjgov.org/ehd Jeff Catruesco, R.E.H.S. SITE HEALTH & SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: + / Address: : L/J - ConmmPerson: r_�� Phone #: q-2,( A �%Q Proposed Date of investigation/inspection: C, _ Z�J 1 2. Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Tank/Pipe Removal ❑ Re cavation ❑ Sampling ❑ Boring / Monitoring Well installation Hazardous Waste inspection ❑ Tiered Pemutting inspection 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: 4. Type ofD�eration: � AA,,h) f . � AA,) 1 ik k A, I -A ' WAS h ) Nlfn. I 9AL / C'mve lce Sim L 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: Potential Health & SafeV Physical Concems: (✓ all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation (falls, trips, slipping, cavo -ins): ❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): Narrative (provide all infortnation which could impact Health and Safety, e.g., power lines, integrity of dikes, twain, etc.): EH 23081 (8/6/2010) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards Caroinogens: 5�,. IT w�yvYl ❑ Corrosives: ❑ Dusts: ❑ Explosives: I aFlammables: "Vltl 1 , ! �-t,�lJ✓In ❑ Inorganic Gases: ❑ Metal, ❑ Oxidu ❑ 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 med/shwk 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: /1 Date: Plan Approved by: j�%` Date: