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r.ao.>A�.coc <br /> ENVIRONMENTAL HEALTH DE,'PARTMENT <br /> • o+'i;izap;.a• SAN JOAQUIN COUNTY Program Coordinators <br /> 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 JeffCatruesco,R.E.H.S. <br /> Web: www.sjgov.org/chd 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 PART II <br /> GENERAL SITE INFO RMA ION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards�c^ry,�7c <br /> Address: garcinoens: r`i"" <br /> Contact Person: El corrosives: <br /> Phone N: YP5Y- o 01 ❑Dusts: <br /> Proposed Date of investigation/inspcction:, ❑Explosives: <br /> Mlammables: <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 /> dous Waste inspection ❑Tiered Permitting inspection <br /> ❑Hazardous Materials Business Plan PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other: ❑Detector Tubes(specify): <br /> �l ❑Photo ionization Detector <br /> 4. Type of Operation: �-Y � �� ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: KNone(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& ❑Hard Hat <br /> describe) ❑Safety Glasses/Goggles <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ;R tcel toed/shank shoes or boots <br /> ❑Noise Sources: ❑Flame retardant coveralls <br /> ❑]Oxygen Deficiency: E]Hewing protection <br /> excavation(falls,trips,slipping,cave-ins): E]Tyvek <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Respirator: ❑APR ❑SCBA <br /> A/P Cartridge: <br /> ❑Confined space entry(explosions): ❑Safety vest <br /> X14eavy equipment(physical injury&trauma resulting from moving ❑Two-way communication <br /> equipment): ❑Other(specify): <br /> ❑Other(specify): <br /> PART IV <br /> 7. Anticipated Biological Hazards: PLAN APPROVAL <br /> ❑Snakes Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify); _ Jc <br /> Plan Prepared b : ate: <br /> 8. Narrative(provide all information which could impact Health and Safety, plan Approved by: U Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> EH 23081(4/30/2013) <br />