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ENVIRO NTAL HEALTH APARTMENT"� <br />8 <br />Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY Program 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 />Web: www.sigov.org/ehd Jeff Carruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: LL, J L ?->00 <br />Address: CA r rdA�(�I 1Qs��r ; 'nra ala <br />Contact Person: Phone #: <br />Proposed Date of investigation/inspection: '� <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation ❑ UAR Investigation <br />❑ Tank Closure in Place ❑ Tank/Pipe Repair <br />❑ Tank/Pipe Removal ❑ Re -excavation <br />❑ Sampling ❑ Boring / Monitoring Well installation <br />Q Hazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />4. Type of <br />5. Release History <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health & Safety Physical Concerns: (✓ all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />Q"Excavation (falls, trips, slipping, cave-ins): <br />/Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />❑ CC nfined space entry (explosions): <br />I� Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Odrer (specify): <br />7. Ant' ted Biolo 'cal <br />Ant <br />Insects Rodents NJ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (3/16/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />7i Is Hazards <br />nogens:_ <br />❑ Corrosives: <br />�>usts: <br />(� plosives:bl ,5 W <br />Flammables <br />❑ Inorganic Gases: <br />[Metals: i IQl(i , <br />❑ Oxidizers: <br />❑ PCBs: <br />Other:1w <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />I. Monitoring Equipment (Note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided): <br />❑ Combustible Gas/Oxygen Meter <br />❑ Detector Tubes (specify): <br />❑ Photo ionization Detector <br />❑ Organic Vapor Analyzer <br />❑ //Other (specify): <br />E34ne (see below) <br />If monitoring instruments are not used, rationale or activity/area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat <br />® Safety Glasses/Goggles <br />® Steel toed/shank shoes or boots <br />❑ Flame retardant coveralls <br />® Hearing protection <br />❑ Tyvek <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P Cartridge: <br />® Safety vest <br />❑ Two-way communication <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared Dater <br />Plan Approved by: Date: 7 <br />