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aSt!?11v. <br /> z ENVIROAIENTAL HEALTH DLPARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. <br /> Director 600 last Main Street, Stockton,California 45242 Kase Y L.Foley,R.E,H.S. <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/chd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: ' 3 Carcinogens: 615 <br /> Contact Person: Corrosives: a=4 <br /> Phone#f: ❑ Dusts: <br /> Proposed Date of investigation/inspectiow 6416 ❑Explosives: <br /> �41`larnmables: ,_r <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:511J G ? <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> azardous Waste inspection ❑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 /> f ❑ Detector Tubes(specify): <br /> 4. Type of Operation: <br /> F) Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> Yone(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 (D D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: 0 Safety Glasses/Goggles <br /> El Oxygen Deficiency: (E Steeltoed/shank shoes or boots <br /> excavation(falls,trips,slipping,cave-ins): El Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.); T g Protection <br /> yvek <br /> ❑Confined space entry(explosions): ❑Respirator. ❑APR ❑SCBA <br /> �eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): 0Safety vest <br /> ❑Other(specify): Two-way communication 'ph,OT AL2 <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> (m ` <br /> akes Insectstodents El Poisonous Plants PART IV <br /> ❑Other/Unknown(specify_):` PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, plan Prepared ca Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH 2308I (3/5/2012) <br />