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2 so44�.coc <br /> w ENVIRONOENTAL HEALTH DO. ARTMENT <br /> •�{�/FORa`p <br /> Donna K.Reran,R.E.H.S. SAN JOAQUIN COUNTYHogram Coordinators <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,RE.H.S. <br /> Web:www.sigov.org/ehd Linda Turkatte,R.E.H.S. <br /> WE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: <br /> Vltazcinogens:6.S <br /> Contact Person: ❑Corrosives: <br /> Phone#: 9) 7 --77/0 ❑Dusts: <br /> Proposed Date of investigation/inspection: q Z <br /> ❑Explosives: <br /> - �'lammables: t LQL_ <br /> 2. Description and brief narrative of inspection activity: E]Inorganic Ga <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 /> Y3azazdous 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 /> L //// ny,� ❑Detector Tubes(specify): <br /> 4. Type of Operation: R b/`bh D//� L//tL/rCV ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO )a None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale m activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concent&(✓all that apply&describe) Level of Protection: EIA ❑B ❑C OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ox0"0 Soames: ®Safety Glasses/Goggles <br /> oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ,dandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Meavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): Two-way communication ""— <br /> ❑Other(specify): <br /> 7. Anticipated Rollical Hazards: <br /> ❑Snakes Insects Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> _ c <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: t rt <br /> e.g.,power lines,integrity of dikes,terrain,etc.): , --1 <br /> Plan Approved by: Wr" Date: c1 11✓ <br /> EH 23081(3/5/2012) <br />