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T <br /> �aRQP!N, <br /> ENVIRONtlENTAL HEALTH APARTMENT <br /> Donna K.Heraa,R.E.H.S. SAN JOAQUIN COUNTYProgram 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 McClellan,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 /> PARTI PARTII <br /> GENERAL SITES IINEORMAATu1N sOs�-y-� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Names./� / -� ✓ I I. Chemicals Hazards <br /> Address: r—'A(C(,{J. 7J2/p-pI ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: L206Dusts: <br /> Proposed Date of investigationlinspection: ❑Explosives: <br /> lammabla:ip�ri✓rt S. r -0y <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑LAR 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 /> 1, ,Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUH)MENT <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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑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 OD <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Hard Hat <br /> ❑Noise Sours: ®Safety Glasses/Goggles <br /> [I,oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> zcn ( P falls,trips,avation slipping,cave-ins): ❑Flame retardant coveralls <br /> dling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®Hearing protection <br /> �Oa ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Aspirator: ❑APR ❑SCBA <br /> [I Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest I� <br /> C]Other(specity): Two-way communication/""ZX _ <br /> ❑Other(specify): <br /> 7. Anticipated B(°lo ''cal Hazards: <br /> maks Insects Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared _ Date: <br /> e.g.,power lima,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V Date. <br /> EH 23081(5/52011) <br />