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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase a Pole R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y y. <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 PART II <br /> GENERAL SITE INFFORMATIOI� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: c I. Chemicals Hazards <br /> Address: 0ElI - ❑Carcinogens: l� <br /> Contact Pelson: ❑Corrosives: til <br /> Phone#: rht 9-t-1 1' 7' ElDusts: <br /> Proposed Date of investigation/inspection ❑Explosives: <br /> ,ffFlammables: ff <br /> 2. Description and brief narrative of inspection activity: l"Inorganic Gases t71f6*1 <br /> ❑New UST installation ❑UAR 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 /> Hazardous 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([Mote: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: !��',tlz,([G/�,kha {�i/Lon 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. tential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ® <br /> Heat or Cold Stress: —746"4 L6 °F(high ambient temp:) Hard Hat <br /> -16oise Sources: f�' n ®Safety Glasses/Goggles <br /> -Q"Oxygen Deficiency: "f I�Q Q t6n r421`IVlkQ ❑Steel toed/shank shoes or boots <br /> ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): <br /> Hearing protection <br /> El Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):_ <br /> ® <br /> ❑Tyvek <br /> ❑ ❑ ❑ <br /> Confined space entry(explosions): Respirator: APR SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> m <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Inticipated Biological Hazar <br /> Snakes [hnsects Rodents C1Poisonous Plants PART IV <br /> Other/Unknown(specify: PLAN APPROV <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: `�" `" Date-6z <br /> e.g.,power lines,integrity of dikes,terrain,etc.): !} <br /> L- <br /> Plan Approved by: Date: (/ U <br /> EH 23081(5/912011) <br />