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. ��••.oma <br /> Ewiv TMENTAL HEALTH I ;PARTMENT <br /> Donna K.Herrn,R.E.H.S. JOAQUIN COUNTYE.H.S. 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 /> Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART T <br /> GENERAL SITE WqRMATION n EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: LO U �K_(o I'.r�c ��s 1• Chemicals Hazards <br /> Address: Iv r` s <br /> ❑Carcinogens: <br /> Contact Person: <br /> Phone#1: ❑Corrosives: <br /> 0 Dusts: <br /> Proposed Date of mvestigation/inspecnon: 2 t 0 Explosives: <br /> 0 Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> 0 New UST installation 0 UAR Investigation 0 Metals: <br /> 0 Tank Closure in Place 0 Tank/Pipe Repair <br /> ❑Oxidizers: <br /> 0 Tank/Pipe Removal <br /> ❑Re-excavation PCBs: <br /> 0 Sampling 0 Boring/Monitoring Well installation ❑Other: <br /> —t54lazardous Waste inspection 0 Tiered Permitting inspection <br /> PART III <br /> 3. TankNo <br /> Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Co.: Tank Capacity. 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Age: operations unless appropriate rationale or restrictions areprovided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: <br /> ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: 0 Other(specify): <br /> Evidence of leaks/soil contamination: 0 YES 0 NO 0 None(see below) <br /> Documented Groundwater contamination: 0 YES 0 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: 0 A 0 B 0 C ®D <br /> 0 Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> 0 Noise Sources: ®Safety Glasses/Goggles <br /> 0 Oxygen Deficiency: ®Steel toed/shank shoes or boots i <br /> excavation(falls,trips,slipping,cave-ins): 0 Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): 0 Heating protection <br /> 0 Tyvek <br /> 0 Confined space entry(explosions): 0 Respirator: ❑APR ❑SCBA <br /> 0 Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> 0 e'er(specify): ❑Two-way communication <br /> Other(specify): <br /> 7. Anticipated Biological Hazards; <br /> 0 Snakes 0 Insects 0 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 b -Z /) <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Date:: <br /> Plan Approved by: Date:Jam) <br /> ' T <br /> i <br /> EH 23081(12/6/2010) <br /> I <br />