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'(�Ullr <br />'CO <br />r. r ENVIRONMENTAL HEALTH D PARTMENT <br />. <br />o�:� SAN JOAQUIN COUNTY Program Coordinators <br />Donna K. Heran, R.E.H.S. Kase L. Fol R.E.H.S. <br />Director 600 East Main Street, Stockton, California 95202 y ey, <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 <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SIT I F RMATION <br />1. Site Name: PWW &A"t <br />Address: <br />Contact Person: <br />Phone #: t3 01611 <br />V <br />Proposed Date of investigation/inspection: &10(b <br />2. 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 />[-�Aazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />4. Type of Operation: <br />off (brn � E Iii, pad-& f'tr t6al Ae, (qal 3 <br />5. 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: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />❑ Other <br />Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />Narrative (provide all information which could impact Health and Safety <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (7/12/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards��� <br />-Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />JEJ"Flammables: <br />leinorganic Gases: 7, <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />❑ Other: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />I . 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 />❑ None (see below) <br />If monitoring 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 />❑ Two-way communication <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by:QI <br />Date: Un `0 i <br />Plan Approved by: u4j, Date: ( l ( Q <br />