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OP41V 1N• C <br />z ENVIRONMENTAL HEALTH D4E?ARTMENT <br />c ..• �P SAN J®AQUIN COUNTY Program Coordinators <br />4�fRORA Donna K. Heran, R.E.H.S. Kasey L. Foley, R.E.H.S. <br />Director 1868 E. Hazelton Ave., Stockton, California 95205 Robert McClellon, R.E.H.S. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Jeff Carruesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br />Rodney Estrada, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN Adrienne Ellsaesser, R.E.H.S. <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: Elon Inc. <br />Address:17333 S Comconex Rd <br />Contact Person: Robert Evans <br />Phone #: 239-3079 <br />Proposed Date of investigation/inspection: 5/13/2013 <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 />❑ Hazardous Materials Business Plan <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />4. Type of Operation: Trucking <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: (check all that apply & <br />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 />equipment): <br />❑ Other (specify): <br />Anticipated Biological Hazards: <br />® Snakes ® Insects ® Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />® Carcinogens: Oils <br />❑ Corrosives: <br />® Dusts: Grindings <br />❑ Explosives: <br />® Flammables: Diesel <br />❑ Inorganic Gases: <br />® Metals: Grindings, sand blasting <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 />® 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 <br />A/P Cartridge: <br />❑ Safety vest <br />❑ Two-way communication <br />❑ Other (specify): <br />❑ SCBA <br />PART IV <br />PLAN APPROVAL {/ <br />Plan Prepared by: Date: E /® — <br />8. Narrative (provide all information which could impact Health and Safety, Plan Approved by: <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (5/10/2013) <br />Date: <br />