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ENVIROT�NENTAL HEALTH LEPARTMENT <br /> PgU1N SAN JOAQUIN COUNTY <br /> Unit Sup ervisors <br /> r' a <br /> Donna K Haran,RE.H.S. <br /> 101 " Director 304 East Weber Avenue, Third Floor Carlggins, n,R.E.H.S. <br /> AI Olsen,RE.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> cv�iFORiivPS. <br /> Douglas Wilson, <br /> Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> A. <br /> Laurie og Manager Co R.E.H.S. <br /> Program ManFax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Park Avenue Cleaners 1. Chemicals Hazards <br /> Address:2529 Tracy Blvd,Tracy.CA ❑Carcinogens: <br /> Contact Person:Mike Brar Phone No:(209)832-3706 ❑Corrosives: <br /> Sweeps Number: E Dusts: <br /> Proposed Date of investigation/inspection:November 1.2004 E Explosives: <br /> E Flammables: <br /> 2. Description and brief narrative of inspection activity: E Inorganic Gases: <br /> ❑New UST installation. ❑OAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> E Hazardous Waste Inspection ❑Sampling. PART III <br /> 3. Specific Site Information* REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. Monitoring Equipment(note:Monitoring instruments must he used for all <br /> Tank Content Tank Age: operations unless appropriate rationale or restrictions are provided) <br /> Other: El Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:Dry Cleaner ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> [3 Other,specify. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: El YES ENO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ENO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C OD <br /> Physical Concerns:(check all that apply&describe) E Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) E Safety Glasses/goggles. <br /> E Noise Sources:Traffic E Steel toed/shank shoes or boots. <br /> El Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> E Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, [I Tyvek. <br /> etc ): E3 Respirator: El APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving E Safety vest. <br /> equipment): E Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> Plan Prepared b ' Date: � <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc):UNKNOWN <br /> EH 23081(12/17/2002) <br />