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i.��Ra�cot AARTMENT ENVIRONM•ENTAL HEALTH <br /> °42tbctia��.� SAN JOAQUIN COUNTY ProgramCoordtnators <br /> Donna K.H R.E.H.S. 600 EMain SStockton,California 95202 <br /> Direrectorctor East treet, <br /> ICasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellan,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 PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name2 1. Chemicals Hazards <br /> Address: () �CCaroinogens: �+.Cf QI.Lr' //�PGfoYICYL?�� <br /> Contact Person: ❑Corrosives: <br /> Phone [IDusts: <br /> Proposed Date of investigation/inspection: Explosives: <br /> �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 /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> >a{azardow Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Infomnation: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Conten Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other. ❑Combustible Gm/Oxygen Meter <br /> /� /���, ❑ Detector Tubes(specify): <br /> 4. Type of Operation: Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO �?Qone(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/am 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 N D <br /> ❑Heat or Cold Stress: OF(high ambient temp.) N Hard Hat <br /> ❑Noise Sources: N Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: N Steel toed/shank shoes or hoots <br /> "SD Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> L�hHHazardous andling and Transfer of a Hardous Substance(fire,explosions,etc.): N Hearing protection <br /> //�� ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> '5jl3Ieavy equip_ ✓a.1,'' ry& meulting from moving A/P Cartridge: <br /> equipment): nrou <br /> N Safety vest ��-�yy� � <br /> ❑Other(specify): TWO-way communimtion"-L6VLC_, <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Snakes �nsects �itodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: <br /> e.g.,power tines,integrity of dikes,tenain,etc.): <br /> Platt Approved by: Date: <br /> EH 23081(5/5/2011) <br />