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e < <br /> ENVIRONMENTAL HEALTH DktARTMENT <br /> Donna K. SAN JOAQUIN COUNTY Program Coordinators <br /> Director <br /> r 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 II <br /> GENERAL SITE INF�AT ON EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: '(, C' 1. Chemicals Hazards <br /> Address: I Carcinogens: <br /> Contact Person: K2— Of Corrosives: <br /> Phone p: ❑Dusts: <br /> Proposed Date of investigation/inspection: F ❑Explosives: <br /> lammables: <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 /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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 /> I ❑Detector Tubes(specify): <br /> 4. Type of Operation: aAl l.�11 Ll/Y �i/J ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES .K NO None(see below) <br /> Documm <br /> ented Groundwater contamination: C]YES I�NO If m nitonng 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 So <br /> Heat or Cold Stress: 1 10 °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,nips,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 AT 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 APPROVAL 1 11J <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan prepared y, Date: " <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Dace: <br /> EH 23081(6/4/2010) <br />