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PqurN <br /> ao. .go <br /> ENVIRONMENTAL HEALTH DART <br /> MENT <br /> SAN gt� JOAQUIN COUNTY <br /> FORa 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 Catruesco,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: Q.,n Ir r I. Chemicals Hazards //`_� <br /> Address: 2$� S � nL *arcinogens: L� arl-hTI.�Q.Z1IJ <br /> Contact Person: I-V7 hjQ'a/ ❑Corrosives: <br /> Phone#: — 1,2)04 ❑Dusts: <br /> Proposed Date of investigation/inspection: — 31-,7,2— ❑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: /Vjl <br /> ❑Tank/Pipe Removal ❑ Re-excavation ❑PCBs: Q <br /> ampling ❑ Boring/Monitoring Well installation ❑Other: <br /> rdous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: l. 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 /> � A + ' ❑Detector Tubes(specify): <br /> 4. Type of Operation: V t �C�� ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑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 Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> '�;�eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): "5a'fwo-way communication P(i671t_ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes '16sects ❑ Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prcpared by Date:C//.":> <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V ` Date: <br /> EH 23081(12/16/2011) <br />