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�a4r8ptH <br /> n: ENVIRO 1 IENTAL HEALTH AARTMENT <br /> SAN JOAQUIN COUNTY <br /> ctFaRa Program Coordinators <br /> Donna K.Resor R.E.H.S. 600 East Main Street, Stockton, California 95202 <br /> Director Kaley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellan,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 /> PARTI PARTII <br /> GENERAL SITE INFO AT[ON EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: 1. Chemicals Hazards Bryn r V/, ,, <br /> Address: Carcinogen S 0/1 l &e'e <br /> Contact P ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> �ammables: <br /> 2. Description and brief narrative of inspection activity: Inorganic Gases: t0 <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizers: F)kU <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 /> �,r ❑Detector Tubes(specify): <br /> 4. Type of Operation: 1 �x`�r✓r 1"l-rt+, / t t�F/Ul-/t-lX/ ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NOtone(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 OD <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 /> 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 ❑ SC BA <br /> �eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> uipment): (E Safety vest ,^ <br /> ❑ <br /> Other(specify): �. -o-way communication P/LXe� <br /> ❑Other(specify): <br /> 7. tpated 8'010 'car Hazards: <br /> rakes ects [ Rbdents ❑Poisonous Plants PART IV <br /> Other/Unldtown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by. Date: !' <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Dale: ! Yl <br /> EH 23081(3/5/2012) <br />