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Nt tK ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> dCisbW <br /> Donna K.Heron,R.E.H.S. 1868 E. Hazelton Ave., Stockton,California 95205 Kasey L.Foley,R.E.H.S. <br /> Director <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 /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: 1. Chemicals Hazards <br /> Address: p ❑Carcinogens: <br /> Contact Person:_ ] 1 , El corrosives: <br /> Phone k: ' 1 ❑Dusts: <br /> Proposed Date of investigation/inspection: IJ _ ❑Explosives: <br /> ❑Flammables: - <br /> 2 Description and brief narrative of inspection activity: ❑Inorganic Gases: n) VlIA9 NN <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 /> )Pazardous 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: r 04� ❑Photo ionization Detector <br /> 'S ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES []NO <br /> ❑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 /> ✓all that apply&describe) Level of Protection: ❑A [IB ❑C ®D <br /> 6. Potential Health&Safety Physical Concerns:( ) <br /> El ®Hard Hat Heat or Cold Stress: IF(high ambient temp.) H Safety Glasses/Goggles <br /> ❑Noise Sources: <br /> ®Steel tced/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 /> El Respirator: El APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): <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 1 Date: 0 <br /> S. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: .1--4� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): `A <br /> Plan Approved by: r!/ Date: ( 2 <br /> EH 23081(7/13/2012) <br />