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P4Ut� <br /> .x� ENVIRON ENTAL HEALTH D 'ARTMENT <br /> • CgCrpO.µa�P. SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K. Heran,R.E.H.S. <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 Catnresco, 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 /> 1. Site Name: P' F-";S0rj 1. Chemicals Hazards y ,y <br /> Address: •�l�i carcinogens:�IS i� � Ze <br /> Contact Person: ❑Corrosives: <br /> Phone#: -�(:) '�busts:�0 1 <br /> Proposed Date of investigation/inspection: ' b Explosives: <br /> -,4Flammables: � t <br /> f <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 /> I lazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: L 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: ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO �pne(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 [I D <br /> F1 Heat or Cold Stress: IF(high ambient temp.) Z Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> []Oxygen Deficiency: Z Steel toed/shank shoes or boots <br /> YZxcavation(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): 0 Safety vest <br /> ❑Other(specify): Two-way communicationv� � <br /> ❑Other(specify): <br /> 7. Anticipated Biological Ha rds. <br /> makes Insects Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL / <br /> S. Narrative(provide all information which could impact Health and Safety, Plan Prepared Dater <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: �� Date:2 27/'l <br /> EH 2308 t(12/16/2011) <br />