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c`�44A�co <br /> ENVIRONIENTAL HEALTH DRARTMENT <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY <br /> •�itikoa~v�• Program Coordinators <br /> Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd teff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFj ATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:--f1 (]_ 1. rCr��..hh�emicals Hazards <br /> Address: bfCarcinogens: <br /> Contact Person: 2 onwives: <br /> Phone H: "6- Dusts: <br /> Proposed Date of investigation/inspectiow ❑Explosives: <br /> lammables: <br /> 2. Description and brief narrative of inspection activity: 0 Inorganic Gases: <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 /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PARTIH <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 /> Q <br /> �rr�yyr� ❑Detector Tubes(specify): <br /> 4. Type of Operation: W/A CSU//, ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES [rVO 0 None(see below) <br /> Documented Groundwater contamination: ❑YES RNO 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 OD <br /> UHeat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> zNoise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®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.):, ®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): ®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 APPROV / ��e <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: "'_ Date: 1 " <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V.&J Date: �0'll•47 <br /> EH 23081 (6/23/2010) <br />