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aA�a.£o <br /> z ENVIRONMENTAL HEALTH DEPARTMENT <br /> C <br /> •.o�C/'sakes' <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,RE.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd JeffCatruesco,R.E.H.S. <br /> SIU HEALTH&SAFETY PLAN <br /> PARTI PART II <br /> GENERAL SITE INFQRMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: (, 1. Chemicals Hazards 1 <br /> Address: j2tarcmogens: ) &-&C <br /> Contact Person: A rl E)Corrosives: <br /> Phone p: ❑Dusts: <br /> Proposed Date of investigatiot mspectimE 0421-11 ❑Explosives: �^ " <br /> _211amnables: <br /> 2. Description and brief narrative of inspection activity: ED Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repan ❑Oxidizers: ` <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART M <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 /> ",,1 ❑Detector Tubes(specify): <br /> 4. Type of Operation: Y`Gl a 1( mA. + r:zmd ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) <br /> Documented Gmundwater 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 ED <br /> ❑Heat or Cold Stress: OF(high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Gogglm <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(Fire,explosions,etc.): E Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): Cl Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects -e-Rodents ❑Poiscrous Plants PART IV <br /> Cl Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by:'� Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: U Date: { 4' <br /> EH 23081(8/62010) <br />