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rxa44�,PAc <br /> _< ENVIRONMENTAL HEALTH DEPARTMENT <br /> �a<F6aN <br /> Donna K.Haran,R.E.H.S. SAN JOAQUIN COUNTY ProgramCoordfnotors <br /> Director 1868 E.Hazelton Ave.,Stockton,California 95205 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> ov.or ehd JeffCarnresco,RE.H.S. <br /> Web:www.s <br /> Jg P� Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL STIE INFO T Crr EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: ) 1. Chemicals Hazards <br /> Address: ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone NDusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> ❑Hammables: <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 ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> � jj <br /> El Detector Tubes(specify): <br /> 4. Type of Operation: {-eej ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> S. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamination: ❑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 /> & Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> C]Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL ^� <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared bya J - i./ll�t/1 Y 1(/oY.� Date: 'Q_. L� <br /> PPe.g.,power lines,integrity of dikes,terrain,etc.): �] <br /> Plan Approved by: IyU 6 Date: 10 <br /> EH 23081(8/14/2012) <br />