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4urti' <br /> r. ENVIRONMENTAL HEALTH D? <br /> ARTMENT <br /> Donna K.Haran,R.E.H.S, SAN JOAQ V I COUNTY Program Coordinators <br /> �fFbN <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,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 INFO ATIO ,, EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: � u�_[�.A/�1 I. Che cats Hazards <br /> Address: • 2� arcinogens: & I <br /> Contact Person: joh 0 9Conosives: <br /> Phone#: G +¢ ,� ❑Dusts: <br /> Proposed Date of investigation/inspection: f f ! ❑Explosives: <br /> C50,1aminables: 'Ot'I <br /> i <br /> 2. Description and brief narrative of inspection activity: lRInorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizers: Q <br /> ❑Tank/Pipe Removal ❑Re-excavation PCBs: <br /> ❑Sampling PBoring/Monitoring Well installation tX Other: 00fn ) <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 /> ff;� /� { /� <br /> El Detector Tubes(specify): <br /> 4. Type of Operation: t/�X/} "� U l� 1/ ) ❑Photo ionization Detector- <br /> C1 <br /> etector❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks 1 soil contamination. NO❑NO done(see below) <br /> Documented Groundwater contamination: YE S ❑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 Dcficicncy: ®Steel toed/shank shoes or boots <br /> cavation(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): wo-way communication 121 <br /> Other(specify): <br /> 7. tlAnticipated Biological HTi ) <br /> : <br /> /�}Snakes sectsodents ❑Poisonous Plants PART IV <br /> ❑Other/U own(spec 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(51512011) <br />