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Pytu r ly. <br />z s ENVIRON XtENTAL HEALTH DEPARTMENT <br />���iFoai;:' • 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 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 <br />PART II <br />GENERAL SITE INFORMATION <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: 300 <br />1. Chemicals Hazards <br />Address: <br />,,,, <br />carcinogens: D(M� ft of <br />Contact Person: <br />❑ Corrosives: <br />Phone #: Z <br />❑ Dusts. <br />Proposed Date of investigation/inspection: 12 fol ZU l I <br />'Explosives: `M2 <br />❑ Flammables: <br />2. Description and brief narrative of inspection activity: <br />❑ Inorganic Gases: <br />❑ New UST installation ❑ UAR Investigation <br />❑ Metals: <br />❑ Tank Closure in Place ❑ Tank/Pipe Repair <br />❑ Oxidizers: <br />[I Tank/Pipe Removal ❑ Re -excavation <br />❑ PCBs: <br />F1Sampling ElBoring / Monitoring Well installation <br />e_ <br />,-Other. aO A& P/1.; <br />Hazardous Waste inspection E]Tiered Permitting inspection <br />PART III <br />3. Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank No.: Tank Capacity: <br />1. Monitoring Equipment (Note: Monitoring instruments must be used for all <br />Tank Content: Tank Age: <br />operations unless appropriate rationale or restrictions are provided): <br />Other: <br />❑ Combustible Gas/Oxygen Meter <br />❑ Detector Tubes (specify): <br />4. Type of Operation: m AJh� in "(MI 04 E] Photo ionization Detector <br />' <br />'%q(►,,ei 0 f��L �� <br />"'1 <br />C1 Organic Vapor Analyzer <br />5. Release History: �J <br />-M- (specify):014" &Ed14 /) La. <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />❑ None (see below) <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />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) <br />Level of Protection: ❑ A ❑ B ❑ C OD <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />® Hard Hat <br />❑ Noise Sources: <br />® Safety Glasses/Goggles <br />❑ Oxygen Deficiency: <br />® Steel toed/shank shoes or boots <br />[2'Excavation (falls, trips, slipping, cave-ins): <br />❑ Flame retardant coveralls <br />B'Randling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />® Hearing protection <br />❑ Tyvek <br />❑ Confined space entry (explosions): <br />❑ Respirator: ❑ APR ❑ SCBA <br />Heavy equipment (physical injury & trauma resulting from moving <br />A/P Cartridge: <br />equipment): <br />® Safety vest <br />❑ Other (specify): <br />❑ Two-way communication <br />❑ Other (specify): <br />7. Antra ated Biological Hazards: <br />snakes Insects 01R-odents ErPoisonous Plants <br />PART IV <br />❑ Other/Unknown (specify): <br />PLAN APPROVAL <br />8. Narrative (provide all information which could impact Health and Safety, <br />Plan Prepared by: Date: I/ <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />r�. 11 <br />Plan Approved by: LU I Date '� 11� <br />EH 23081 (5/9/2011) <br />