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>aR�o 'Ati <br /> F EN"RONXIENTAL HEALTH DE'TARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> •o tt'eU+m Donna K.Heran,R.E.H.S. Kasey L.Foley,RE.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 JeffCarruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PART 11 <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: qC5-0 -I"7 7/7/Ails 7 ❑Carcinogens: <br /> Contact Person: Cortosives: <br /> Phone#: 2 a 0 L Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: l <br /> )EJ 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 ❑PCBs: <br /> C-1sampling [3 Boring/Monitoring Well installationOtherI.f.YN <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART m <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank A e operations unless appropriate rationale or restrictions we provided): <br /> Tank Content g <br /> ❑Combustible Gas/Oxygen Meter <br /> Other: <br /> ❑Detector Tubes(specify): <br /> 4. Type <br /> ype of Operation:�^� a�fr (/ n{7,/7 Photo ionization Detector <br /> (/ T !/�� rr=-�s�L4 C3 <br /> —�� <br /> E]Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: C]YES ❑NO <br /> Nonc(sec below) <br /> Documented Groundwater contammation: ❑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 ®D <br /> ❑Heat m Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> Gla <br /> gles <br /> ❑Noise Sources: ®Safety ed/shank shoes <br /> ®Stcel toed/shank shoes or boots <br /> Rozygen Deficiency: El Flame retardant coveralls <br /> zcavation(falls,hips,slipping,cave-ins): <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): [3Tyvek. ® protection <br /> on <br /> ❑ ❑ <br /> ❑Confined space entry(explosions): Respirator: E]APR SCBA <br /> khleavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> ®Safety vest <br /> equipment): q� <br /> ❑Other(specify): '-Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> �S rakes k6wts odents ❑Poisonous Plants PART IV <br /> C]Other/Unknown(specify)J: PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V� Date: <br /> EH 23081(5/5/2011) <br />