Laserfiche WebLink
PqurN <br />y ENVIR01AIENTAL HEALTH DPARTMENT <br />C4�IFON a�P • <br />Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY 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, RE.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL <br />1. Site Na: <br />Contact Person: /cJL/ <br />Phone #: �% 13a 20 <br />Proposed Date of investigation/inspection: Q <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 />[Hazardous 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: lC O ' mae <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 />andling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipated Bi logical Hazards: <br />�oSnakes Insects dents ❑ Poisonous Plants <br />9Other/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 (9/15/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />,Carcinogens: <br />Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />❑ Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />❑ Other: <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 />)rNone (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 <br />A/P Cartridge: <br />❑ SCBA <br />® Safety vest �/y,� n <br />theTwo-way Cc if <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared b}. ate: <br />Plan Approved by: ;jrA Date: It -JA -0 <br />