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ENVIROAMENTAL HEALT#DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 2 ? Donna K.Heran R.E.H.S. Unit Supervisors <br /> 304 East Weber Avenue, Third Floor g <br /> Carl Bor man,R.E.H.S. <br /> Director <br /> ,Mike Huggins,R.E.H.S. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Douglas W.Wilson,.S.,R. R.D.I.R. S. <br /> cq. �P Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> C b4 Laurie A.Cotulla,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: sk>Qr_> CoR-P KAR 1. Chemicals Hazards <br /> Address: t 93 2 Pt N0.0 <br /> ❑Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: evs; 'O 1 —06 <br /> ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of operation: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: D <br /> ❑A ❑B ❑C ❑ <br /> Physical Concerns:(check all that apply&describe) 0Hard Hat. <br /> ElHear or Cold Stress: °F(high ambient temp.) OSafety Glasses/goggles. <br /> Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> El Oxygen Deficiency: <br /> ❑ <br /> C]Excavation:(falls,trips,slipping,cave-ins): Hearing protection. <br /> ❑ <br /> C1 Handling and Transfer of a Hazardous Substance:(fire,explosions, Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants t_�%. t,QC.5;S <br /> PlanPreparedby: g a s LX_ Date: <br /> ❑Other/Unknown(specify): J <br /> Plan Approved by: Date: <br /> 8. "Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />