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0.��nrN C <br /> EMgRONMENTAL HEALTH DI�:PARTMENT <br /> ' SAN JOAQUIN COUNTY Program coordinators <br /> Kasey L.Foley,R.E.H.S. <br /> Donna K Heron,R.E.H.S. 600 East Main Street, Stockton,California 95202 Robert McClellon,R.E.H.S. <br /> Director <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Jeff Cmruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R:E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART 11 <br /> PART <br /> GENERAL SITE ORMA�ION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Chemicals Hazards <br /> 1. Site Name: ❑Carcinogens: <br /> Address: <br /> `I/yt, ❑Corrosives: <br /> Contact Perso ell ❑Dusts: <br /> Phone <br /> A'1I I ❑Explosives: <br /> Proposed Date of investigatiodmspea[ion: ❑Flammables: ! <br /> ❑ ... <br /> 2. Description and brief narrative of inspection activity: ❑Metals:, <br /> ❑New UST installation ❑UAR investigation ❑Oxidizers: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑PCBs: <br /> ❑Tank/Pipe Removal ❑Re-excavation <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 Ca ci 1. Monitoring Equipment(Note:Monitoring instruments most be used for all <br /> Tank No.: PaTy' <br /> operations unless appropriate rationale or restrictions are provid <br /> Tank Content: Tank Age: <br /> ❑Combustible Gas/Oxygen Mete,' <br /> Other: rV1 —�`n- ❑Detector Tubes(specify): <br /> �oW (AUI V(. ❑Photo ionization Detector <br /> 4. Type of(OIperation: p .� r"'r^'/�Adr �l'Idl �':YJ�❑orbic Vapor Analyzer <br /> !TU h0 tAX ❑Other(specify): . <br /> 5. Release History: ❑None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ElB ❑C ®D <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Hat <br /> ❑Heat or Cold Stress: °F(high ambient tL1°p.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave ins): ®Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): ❑Two-way communication <br /> ❑Other(specify): ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑inPART IV <br /> sects ❑Rodents Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> L <br /> e.g.,power lines,integrity of dikes,terrain,etc.): V Dater <br /> Plan Approved by: <br /> EH 23081(5/9/2011) <br />