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r4t�!.M <br />ENVIROOMENTAL HEALT EPARTMENT <br />b . SAN JOAQUIN COUNTY <br />• c.p • Program Coordinators <br />......... Donna K. Heran, R.E.H.S. 304 East Weber Avenue, Third Floor Carl Bergman, R.E.H.S. <br />Director <br />Laurie A. Cotulla, RE.H.S. Stockton, California 95202 Mike Huggins, R.E.H.S, R.D.I. <br />Assistant Director <br />Telephone: (209) 468-3420 <br />Fax: (209) 464-0138 <br />Web: www.sjgov.org/ehd <br />SITE HEALTH & SAFETY PLAN <br />Kasey L. Foley, R.E.H.S. <br />Margaret Lagorio, R.E.H.S. <br />Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S. <br />PARTI PARTII <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: W /n�t+C�'1- 1. Chemicals Hazards <br />Address: % «,— ®Carcinogens: <br />Contact Person: ne No: (9q) 3';S'zd6 ORCormsives: <br />Sweeps Number: <br />Proposed Date of investigation/inspection: III c7 12— <br />I <br />2. Description mid brief narrative of inspection activity: <br />❑ New UST installation.. <br />❑ OAR Investigation. <br />❑ Tank Closure in Place.. <br />❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. <br />❑ Re -excavation. <br />❑ Installation of Borings / Monitoring <br />Wells. <br />J9 Hazardous waste inspection <br />❑ Sampling <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Heat or Cold Stress: OF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fixe, explosions, <br />[K Dusts: <br />Flarmnables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />❑ Confined space entry: (explosions): ® Safety vest. <br />❑ Heavy equipment (physical injury & trauma resulting fi-om moving ❑ Two-way communication. <br />equipment): <br />❑ Other, <br />7. Anticipated Biological Hazards: <br />❑ Snakes [X Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health mid Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.) <br />EH 23081 (02/19/03) <br />PART IV -PLAN APPROVAL <br />Plan Prepared by: M Naidu Date: i l <br />Plan Approved by: R (% Date: 12 <br />