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}quip <br /> �a .eo <br /> ENVIRONMENTAL HEALTH D -PARTMENT <br /> c tifFoaa��`� SAN JOAQ V IN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Fol R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y eye <br /> Telephone;(209)468-3420 Fax:(209)468-3433 Robert McClelion,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 INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: I. Chemicals Hazards <br /> Address: CJ Carcinogens:(, <br /> Contact Person: Corrosives: <br /> Phone#: On, ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: A <br /> X Flammables•—St A 141A U <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 /> El <br /> ❑Sampling El Boring/Monitoring Well installation ❑Other: Ll.v L1 C l (� bl`l� <br /> XHazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3, Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: _- Tank Capacity: I. 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(spccify): <br /> 4. Type of Operation: ❑Photo ionization Detector <br /> [3 Organic Vapor Analyzer <br /> 5. Release History: C]Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO None(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 ®D <br /> ❑Heat or Gold Stress: IF(high ambient temp.) <br /> Hard Hat <br /> wise Sources: A�,� 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 ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> ®safety vest <br /> equipment): <br /> ❑Other(specify): YT3w1-way communication YLQ_ <br /> ❑Other(specify): - <br /> 7. Anticipated Biological Hazards: <br /> Snakes "iZdnsccts , 'orients ❑Poisonous Plants PART IV <br /> ❑Other/Unlmown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepar e: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: � Date: <br /> EH 23081 (5/5/2011) <br />