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T <br /> ENVIRO&NTAL HEALTH APARTMENT <br /> SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Heron,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Kase y L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Can uesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: 1. Chemicals Hazards <br /> Address: ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone p: — ) outs;ena <br /> Proposed Date of investigation inspection: ❑Explosives: <br /> lammables: <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 /> ��` <br /> El Sampling [I Boring/Monitoring Well installation ❑Other: <br /> 1/l Hazardous Waste inspection ❑Tiered Permitting inspection <br /> //-C' PART Iu <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. Typeofoperation: <br /> ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO lKlone(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:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> >accavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> x}Iandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> / ` ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> )14Zesvy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> EQuipmen) ®Safety vest <br /> ❑Other(specify): . Two-way communication AOju„ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> hakes�ects j £odents Cl Poisonous Plants PART IV <br /> er/Unlmown(specify): \ PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b �'✓ <br /> e.g.,power lines,integrity of dikes,terrain,etc.): : <br /> Plan Approved by: Date: <br /> EH 23081(3/5/2012) <br />