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< ENVIRON•MENTAL HEALTH DEPARTMENT <br /> ,�q'�1RUp�;'• <br /> Donna K.H R.E.H.S. SAN JOAQUIN COUNTY program Coordinators <br /> Director <br /> 600 East Main Street, Stockton, California 95202 Kaley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,K.E.H.S. <br /> JeffCarruesco,R.E.H.S. <br /> Web: www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: KM #60a 1. Chemicals Hazards f <br /> Address: �❑i Caroinogws: 1 ti � -Yi- L(/✓K �WCi V1 <br /> Contact Person: — h ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑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: <br /> ❑Tank(Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑k-�nnS"'ampling [I Boring/Monitoring Well installation Cl Other <br /> ty frazardous Waste inspection C]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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: OIQ�� �!}� ❑Photo ionization Detector <br /> �t ❑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 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.): <br /> ®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 /> ❑Other(specify,): Two-way communication Cak ouy'Q <br /> Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑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 by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: �'t"D-10 <br /> EH 23081(8/62010) <br />