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h ENVIROP&T ENTAL HEALTH AARTMENT <br /> Donna K. <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> Director <br /> r 600 East Main Street, Stockton, California 95202 Kasey L.Foley,RE.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 <br /> Address:-70, ❑Caroinogens: //�/r.(V/I/T7'l� <br /> Contact Penson: ❑Corrosives: <br /> Phone#: Cl Dusts <br /> Proposed Date of investigation/inspection: E]Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑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 /> azardous Waste inspection [I 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 most be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> 1� <br /> C]Detector Tubes(specify): <br /> 4. Type of operation: ZZYZ464 l 4Q2/ ❑Photo ionization Detector <br /> Or ❑Organic Vapor Analyzer <br /> 5. Release History: ❑other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO Gone(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 OD <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Hard Hat <br /> oise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> 'Eqxygen n falls,tri E]Flame retardant coveralls <br /> ( trips,slipping,cave-ins): <br /> ®Hearing protection <br /> ARandling and Transfer of a Hazardous Substance(fire,explosions,etc.):, <br /> ❑Tyvek <br /> 777��❑,,,///��C��-onfined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> A/Pl� cavy equipment(physical injury&trauma resulting from moving Safety <br /> Cartridge: <br /> "equipment): ®Safety vest hd_KQ <br /> ❑Other(specify): Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated'Biolofpical Hazards: <br /> makesE(Iusects t6dents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify):✓_ PLAN APPROV:VLJ <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Plan Approved by: Date: ('l <br /> EH 23081(3/5/2012) <br />