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ENVIROMENTAL HEALTHDEPARTMENT <br /> °`" <br /> ). =..r ° SAN JOAQUIN COUNTY <br /> te o� <br /> Donna K.Heran,R.E.H.S. 'E.H.S. Unit Supervisors <br /> 304 East Weber Avenue Third Floor earl BR.E.H.S.an,R.E.H.S. <br /> Director Mike Huggins,R.E.H.S.,R.D.I. <br /> -y. Al Olsen,R.E.H.S. Stockton, California 95202-2708 <br /> - Douglas W.Wilson,R.E.H.S. <br /> • Cq .��P Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> �rFoa Laurie A.Cotulla,R.E.H.S. <br /> Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Bazcellos,R.E.H.S.. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: &w� + WIU'A' 1. Chemicals Hazards <br /> �as{/ <br /> Address: T1MAEf 9-0 M carcinogens: <br /> Contact Person:Mbrw Phone No: Corrosives: <br /> Sweeps Number: usts: <br /> Proposed Date of investigation/inspection: 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. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> SCJ t4l li` V01cf-TI--i ' PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation: <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ������((((((,,,,,, ❑Other,specify. <br /> Evidence of leaks/soil contamination: YES [INO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ❑D <br /> 6. Potential Health and Safety <br /> Hard Hat. <br /> Physical Concerns:(check all that apply&describe) afety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) Steel toed/shank shoes or boots. <br /> "toOise Sources: <br /> ❑Flame retardant coveralls. <br /> Oxygen Deficiency: <br /> ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator: ElAPR ElSCBA <br /> etc..): <br /> A/P cartridge: <br /> ❑Confined space entry:(explosions): (� <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ya�Safety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> []Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: ,] IN Date: <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: 'LO O <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br />