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PgUfN <br /> z ENVIRONMENTAL HEALTH DEPARTMENT <br /> C9�%FOR a�P <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <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 II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:AW&I'FQ-✓ms'pleb :Z71C• 1. Chemicals Hazards <br /> Address: 10 V W• VAX40iC0AU VOL_-/f ❑Carcinogens: <br /> Contact Person: JRCorrosives: 46 d-r <br /> Phone#: 20 go 5 E]Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> tolammables;O%Qm� <br /> 2. Description and brief narrative of inspection activity: 0,Inorganic Gases: OY1_ <br /> ❑New UST installation ❑UAR Investigation ❑ Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair Oxidizers:OW4941 <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑ PCBs: <br /> Uampling ❑Boring/Monitoring Well installation ElOther: <br /> azardous 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:6d� ❑ Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO one(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 SD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) M Hard Hat <br /> ❑Noise Sources: M Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: M Steel toed/shank shoes or boots <br /> Excavation(falls,trips,slipping,cave-ins): 66bldoOrS ❑Flame retardant coveralls <br /> Iandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. M Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): M Safety vest <br /> ❑Other(specify): Two-way communicationp1 Zl� <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> C74nakes Eyfwcts &�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 Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: � Date: 4-�3AV <br /> EH 23081(4/7/2010) <br />