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ip <br />ENVIRONi./IENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Donna K. Heran, R.E.H.S. Program Coordinators <br />Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley, R.E.H.S. <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />Description and brief narrative of inspection activity: <br />❑ New UST installation ❑ UAR Investigation <br />❑ Tank Closure in Place ❑ Tank/Pipe Repair <br />❑ Tank/Pipe Removal ❑ Re -excavation <br />❑ Sampling ❑ Boring / Monitoring Well installation <br />�azardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />(:M44. Type of Operation: -DALL <br />1 <br />Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) <br />❑ Heat or Cold Stress: OF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />xcavation (falls, trips, slipping, cave-ins): <br />dling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />❑ Confined space entry (explosions): <br />eavy equipment (physical injury & trauma resulting from moving <br />dquipment): <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />Snakes sects *odents C1 Poisonous Plants <br />C]Other/Unlmown (specify)): `` <br />8. <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (3/5/2012) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals <br />VCarcinogens:S A_ <br />■D <br />■Explosives: <br />� <br />?a . //. /1� ► [,rte► �. <br />ri <br />■ <br />R• tr,(1 1A..l <br />■ <br />..,� r11, .....10 0-tw <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (Note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided): <br />❑ Combustible Gas/Oxygen Meter <br />❑ Detector Tubes (specify): <br />❑ Photo ionization Detector <br />❑ Organic Vapor Analyzer <br />❑ Other (specify): <br />(see below) <br />IfmoKone <br />g instruments are not used, rationale or activity/area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat <br />® Safety Glasses/Goggles <br />® Steel toed/shank shoes or boots <br />❑ Flame retardant coveralls <br />® Hearing protection <br />❑ Tyvek <br />❑ Respirator. ❑ APR ❑ SCBA <br />A/P Cartridge: <br />® Safety vest <br />KTIwo-way communication <br />❑ Other (specify): <br />' r = <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: Date: <br />Plan Approved by: Date: �' 1 <br />