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�aRyuty <br /> r. 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> •�'+Cjpapi+��, <br /> Donna K Heron,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 1868 E. Hazelton Ave., Stockton, California 95205 Kasey L.Foley,R.E.H.S. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web: wwwsjgov.org/ehd JeffCarruesco,R.E.H.S. <br /> Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMA ION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 9 1. Chemicals Hazards <br /> Address: <br /> Carcinogens:VVl/ rJ �1 <br /> Contact Person: ❑Cormsives:A,bj� <br /> Phone N: ❑Dusts: <br /> Proposed Date ofinvestigation/inspection: Z ❑Explosives: <br /> ❑Flammables <br /> 2. Description and brief narrative of inspection activity: ❑Inorgani Gases: <br /> ❑New UST installation ElUAR Investigation E3 metals: ,AW Oa AtJ pin <br /> ❑Tank Closure in Place E]Tank/Pipe Repair El Oxidizers: <br /> � --' l <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> 1Pazardous Waste inspection ❑Tiered 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 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 /> pp,, ❑Detector Tubes(specify): <br /> 4. Type of Operation: Qul '114W 4 A J g 4— ❑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 E D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E 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.); E 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): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <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' 6Z. <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ���GGG <br /> Plan Approved by: �� Date:�rL <br /> EH 23081(7/13/2012) <br />