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4n�N <br /> vo4�.coc <br /> t� ENVIRONMENTAL HEALTH DEPARTMENT <br /> � CgtiFORN�P.� <br /> Donna K.Heron,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 1868 E. Hazelton Ave., Stockton, California 95205 Kasey 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/ehd 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 p <br /> Address: 'Carcinogens: <br /> Contact Person: El Corrosives: <br /> Phone#:_ .l ❑Dusts: <br /> V <br /> Proposed Date of investigation/in pection: Z I—]Explosives <br /> In <br /> 2. Description and brief narcative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑GAR 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 /> azardous�WKa_ste��inspection ❑Tiered Permitting inspection <br /> Ow 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 /> r ❑Detector Tubes(specify): <br /> 4. Type of Operatipn:_ yyt"l�fit" 0Z iTAANAk!QCh ❑Photo ionization Detector <br /> Tc /�..,;,;n ❑Organic Vapor Analyzer <br /> 5. Release Histo°ryW0.. bi 1'UU--I-NrY vl.� `-�\/0�^' E]Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑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 /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ED <br /> ❑Heat or Cold Stress: OF(high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> E]Excavation(falls,trips,slipping,cave-ins): El Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.).. E Hearing protection <br /> ❑Tyvek <br /> ❑ <br /> ❑Confined space entry(explosions): [I Respirator: APR L]SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): E 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 APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: b I Z <br /> e.g.,power lines,integrity of dikes,terrain,etc.): J/1 <br /> Plan Approved by: Date: <br /> EH 23081(7/132012) <br />