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fiery <br /> r ENVIRONMENTAL_HEALTH DEPARTMENT <br /> m . <br /> .cq< FaaeJ, <br /> Donna K. SAN JOAQUIN COUNTY program Coordinators <br /> Director <br /> r 600 East Main Street, Stockton, California 95202 Kersey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> s ov.or ehd JeffCarruesco,R.E.H.S. <br /> Web:www <br /> JS Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE O ATION ((�II��..,, EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Nay s 1!4D Y f/f- IAV 1. Chemicals /�• �^ <br /> Address: �LI' ,(A-P ,( 'Carcinogens• ,�. t i�:�i� •,. �U10�. <br /> Contact Person:. // /l.✓I ❑corrosives: <br /> Phone#:�v d� Q ❑Dusts: <br /> Proposed Date of investigation/inspection: Explosives: <br /> ❑Flamurables: <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: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> �•{lazardous Waste inspection ElTiered Permitting inspection <br /> �`-' PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments most 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 0peration: h 7M ❑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 Coacems:(✓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 /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑ogle.(spmify): ❑Two-way communication <br /> ❑other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑bisects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL 2j � <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): �j� I <br /> Plan Approved by: (J Date: `�' `� <br /> EH 23081(5/92011) <br />