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H:. P4 er� e `�r. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SA JOAQUI COUNTY Program CoorNmators <br /> �r�oe Donna K.Heran,R.E.H.S. <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 Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART R <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: MS41P 01�1�00vle 1. Chemicals Hazards <br /> Address: carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone 0#: 35 1�l ❑Dusts: <br /> Proposed Date of investigationlinspection: g ( ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigationetals: <br /> ElTank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑'rank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑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 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: rE� /Y __ ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks f soil contamination: ❑YES ❑NO one(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If motonng 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 ❑D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> /Oise Sources: ❑Safety Glasses/Goggles <br /> oxygen Deficiency: ❑Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> NAandling and Transfer of a Hazardous Substance(fire,explosions,etc.):- ®Hearing protection <br /> 17�-' ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> avy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> eq-uipment): Safety vest <br /> Other(specify): Two-way communication <br /> Other(specify): <br /> 7. Anticipated Bi lWical Hazards: <br /> ❑Snakes nsectsRodents ElPoisonous Plants PART IV <br /> •OtherIU nown(spcAm: PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan PrepareDate: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> •1...4.1 <br /> EH 23081 (4/7/2010) <br />