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2' ENVIRONMENTAL HEALTH D PARTMENT <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY <br /> 4��FORea�P 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 /> 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 INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> J5 <br /> 1. Site Name: H"ni' 7?Ark -y �C• 1. Chemicals Hazards <br /> L' <br /> Address: o9JI(1�C �/>/'r!/S UTUC' i7 aroinogens: ��T/�� <br /> Contact Person: ❑Corrosives: <br /> Phone#: Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> VFlaminables: Lf <br /> 2. Description and brief narrative of inspection activity: organic Gases: 417Y1 <br /> ❑New UST installation ❑UAR Investigation etals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> OHazardous 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: ❑ Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: C]Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO Ione(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 ® D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard at „ <br /> El Noise Sources: afety Glasses/Go <br /> ❑Oxygen Deficiency: ®Steel --shank shoes or boots <br /> Flame retardant coveralls <br /> ,excavation(falls,trips,slipping,cave-ins): ❑ <br /> 'Tandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. Q Hearing Protection <br /> Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving fridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): wo-way communication 0-70 Y1� <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hds: <br /> Snakes Insects aodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b Date: �5 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH 23081(2/7/2011) <br />