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a R5l •Id•..co <br /> s< <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �,(raatia� <br /> Donna K.Heron,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 Far:(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 INF O,R�M ArT�IO�N CJ/� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Na'.: &fcx'_ UV!/ aW F'QQ2) 1. Chemicals Hazards I Q <br /> Address:,2q 0 lam)�i - . �Carcinogens:444r' ze' 0d I"QGL D1� <br /> Contact Person, M�ri�1Q�iY(/ ❑Corrosives: <br /> Phone#: 4 vv or ❑Dusts: <br /> Proposed Date of investigation/inspectiow / ^ Cl Explosives: <br /> J$.Flammables: J&4; <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑TanklPipe Repair Oxidizers: _ <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation fE�(Other: O&YT h, <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 /> �( /pt&C ❑Detector Tubes(specify): <br /> 4. Type of Operation: JZ,P fTXAe ! o 4,H&n ❑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 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: OF(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®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.):. ®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): ®Safety vest ,q, <br /> C]Other.(Specify); Two-way I <br /> communication rtOYLQ- <br /> ❑Other(specify): <br /> 7. Anticipated mologrcal Hazards: <br /> Snakes Insects )E61dents C3Poisonous Plants PART IV <br /> ❑OthenUnlmown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prep Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: �" Dale:•v �� <br /> EH 23081(8/112011) <br />