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r <br /> r:�a¢A�cpti <br /> a _< ENVIRON&ENTAL HEALTH APARTMENT <br /> �ici ops;� SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kasey L.Foley,RE.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 Jeff Can uesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> Rodney Estrada,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,RE.H.S. <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: /"f///Q C�h jn✓ r y /r 1. Chemicals Hazards <br /> Address:a2�`><�� W. C-h�-ff/^ 1 -;il ?m ❑Carcinogens: <br /> Contact Person: *orrosives: 6UJr/Ae/' -% <br /> Phone#: ( ❑Dusts: <br /> Proposed Date of investigation/inspection: 3— t ❑Explosives: <br /> ❑Flammables: <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 /> "Wazardous 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 /> ❑Photo ionization Detector <br /> 4. Type of Operation: 1?2Q±b244g CJ /07, eS ❑Organic Vapor Analyzer <br /> � ❑Other(specify): <br /> 5. Release History: gone(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments aro 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 XD <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& ❑Hard Hat <br /> describe) ❑Safety Glasses/Goggles <br /> ❑Heat or Cold Stress: OF(high ambient temp.) tml toed/shank shoes or boots <br /> ❑Noise Sources: Flame retardant coveralls <br /> ❑Oxygen Deficiency: ❑Hearing protection <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑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 /> ❑Heavy 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 /> ❑Snakesnetts ❑Rodents ❑Poisonous Plants <br /> [3Otl--- - own(specify): Plan Prepared b Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date:J_J�J_il_ <br /> e.g.,power lines,integrity of dikes,terrain,etc.): I1 <br /> EH 23081(1/2/2013) <br />