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u�nr <br /> z� ENVIROENTAL HEALTH DWARTMENT <br /> ..c4c5FSAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 t y> <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert MalesMcCleo,R.E.H.S.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 /> PARTI PARTII <br /> GENERAL SITE INF RMATION �1 EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: & v 1. Chemicals Hazards <br /> Address: \0 Carcinogens: <br /> Contact Person-_�fQ1�'1/f // !Corrosives�/�//l/� <br /> q tad <br /> Phone#: — ❑Dusts: <br /> Proposed Date of investigation/inspection: t Z ❑Explosives: -, <br /> 0 Flammables: D om%, phi e <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 /> ❑Sampling ❑Boring/Monitoring Well installation Other: Ac4 a A <br /> Wazardous 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:, o ❑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 ED <br /> ❑Heat or Cold Stress: °F(high ambient temp.) <br /> ®Hard Hat <br /> Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): <br /> �Iandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest y�L� <br /> ❑Other(specify): Two-way communication T/l — <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes 'Insects ❑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 . Date: I� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V Date: <br /> EH 23081(3/5/2012) <br />