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pgH!N <br /> Q: <br /> ENVIRONMENTAL HEALTH APARTMENT <br /> a: < <br /> •.cq.. ,N`p.� SAN JOAQUIN COUNTY program Coordinators <br /> �rPOR Donna K.Heran,R.E.H.S. <br /> 600 East Main Street, Stockton, California 95202 L.Foley,R.E.H.S. <br /> Director Robert <br /> McClellon,R.E.H.S. <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Jeff Carruesco,R.E.H.S. <br /> Weh: www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: O [ O, 1. Chemicals Hazards <br /> Address: Carcinogens: <br /> Contact Person: orrosives: / <br /> Phone k: .'J3 (p ❑Dusts: <br /> Proposed Date of investigationlinspection: g !s /D ❑Explosives: <br /> Whimmables: <br /> 2. Description and brief narrative of inspection activity: Inorganic Gases:&041M <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 /> 'Wazardous Waste inspection ❑Tiered Permitting inspection <br /> PART HI <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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 /> / ' /I ❑Detector Tubes(specify): <br /> 4. Type of Operation:_ All a44 "tt ❑Photo ionization Detector <br /> \\) ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO one(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If mo itoring 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) <br /> Level of Protection: ❑A ❑B ❑C ED <br /> ®Hard Hat <br /> ElHeat or Cold Stress: °F(high ambient temp.) E Safety Glasses/Goggles <br /> Oise Sources: E Steel toed/shank shoes or boots <br /> Oxygen Deficiency: <br /> ❑Flame retardant coveralls <br /> `excavation(fails,trips,slipping,cave-ins): <br /> ®Hearing protection <br /> Warding and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek <br /> [I Respirator: [I APR ❑SCBA <br /> El Confined space entry(explosions): A/P Cartridge: <br /> � <br /> deavy equipment(physical injury&trauma resulting from moving <br /> equipment): E Safety vest rye ,n,� <br /> [I Other(specify): Two-way communication T Kr U— <br /> Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> '�anakes ]1insects rdRodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepar Date: <br /> e.g.,power lines,integrity of dikes,terain,etc.): p <br /> Plan Approved by: Date: <br /> EH 23081(4/72010) <br />