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OP�urN C <br />a z< ENVIRONMENTAL HEALTH D 'PARTMENT <br />SAN JOAQUIN COUNTY Program Coordinators <br />A�1 Foil, 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 I <br />GENERAL SITE INFORMATION <br />1. Site Name: O - <br />Address:/ 7'J'� S. (fO�Y%ft l?Yl� <br />Contact Person: t2Dh2�Z <br />Phone #: c'_0-7 —3021 <br />Proposed Date of investigation/inspection: <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 />'�41azardous 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: /l�p <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: (check all that apply & <br />describe) <br />❑ Heat or Cold Stress: OF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />xcavation (falls, trips, slipping, cave-ins): <br />Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ Confined space entry (explosions): <br />ieavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />nakes -Nisects odents F1Poisonous Plants <br />ILther[Unknown <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (4/30/2013) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />Carcinogens: t.� b s <br />❑ Corrosives: <br />El Explosives: <br />Iammables:d i0'ay <br />❑ Inorganic Gases: <br />Metals: sit . <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 />,)E*afety Glasses/Goggles <br />'96teel 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 b . r Date:! / <br />Plan Approved by: Date: I <br />