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� <br /> ENVIROl&T ENTAL HEALTH IMPARTMENT <br /> �` •.: SAN JOAQUIN COUNTY program Coordinators <br /> crp°ae Donna K.Director <br /> R.E.H.S. <br /> 600 East Main Street, Stockton California 95202 Kasey L.Foley,R.E.H.S. <br /> Director Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 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 INFORMATIONEVALUATION OF POTENTIAL HAZARDS <br /> --,r-�� <br /> 1. Site Namec��f�Q C�7 I 1 ft 1. Chemicals Hazards <br /> Address:. f�CLn A 9carcinogens rj)G. L IA a.O'I-f/J <br /> Contact PElCorrosives: <br /> Phone#- 7,41q g-3- I tea Wusts: A A L - <br /> Proposed Date of investigation/inspection:��_� /Z. ❑Explosives: <br /> Flammablec•r Ir O s <br /> 2. Description and brief nartative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑MSH: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ` Sampling C]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 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 /> ((��,, <br /> /y�t� <br /> El Detector Tubes(specify): <br /> 4. Type of Operation:�o /i Rd � t f�`` ' v ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify)' <br /> Evidence of leaks/soil contamination: ❑YES ❑NO V, None(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 /> Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: Z Steel toed/shank shoes or boots <br /> ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): <br /> Hearing protection <br /> dandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. <br /> ® <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator. ❑APR ❑SCBA <br /> A/P Cartridge; <br /> �X'Heaequipment(Ph Sical inJm'Y&trauma resulting from moveg <br /> equipment): <br /> ®Safety vest �(., // <br /> El Other(specify): Two-way communication iT I I V't�-- <br /> ❑Other(specify): <br /> 7. Anticipated Biolo cal Hazards: <br /> El Snakes 7Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Data. ��/ ��—• <br /> e.g.,power lines,integrity of dikes,terrain,etc.): �(� <br /> Plan Approved by: Dare:" IS) IZ, <br /> EH 23081(3/5/2012) <br />