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obAulry c 0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Donna K.Heron,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <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 /> Jeff Carruesw,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: Chipotle I. Chemicals Hazards <br /> Address: 2310 Tienda ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone u: 2093710881 ❑Dusts: <br /> Proposed Date of investigation/inspection:Jun 5, 2013 ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑OAR 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: CO2 <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> ®Hazardous Materials Business Plan 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation:food ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. 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 /> 6. Potential Health&Safety Physical Concerns:(check all that apply& Level of Protection: ❑A ❑B ❑C NO <br /> describe) ❑Hard Hat <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ❑Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ®Oxygen Deficiency: CO2 ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek <br /> ❑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 /> ❑ <br /> Other(specify): ❑Other(specify): <br /> 7. Anticipated Biological Hazards: PART IV <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> Plan Prepared by: Jamie DeLaRosa Date: Jun 4,2013 <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ^ �( <br /> Plan Approved by: /I�� IiLY Date: Le <br /> EH 23081(8/21/2012) <br />