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lgR4�'�O <br /> t ENVIRONMENTAL HEALTH AARTMENT <br /> �e�tlFcq?s~.� <br /> Donna K.H R.E.H.S. SAN JOAQUIN COUNTY program Coordinators <br /> Director <br /> 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 /> SITE HEALTH At SAFETY PLAN <br /> PARTI PART R <br /> GENERAL SITE INFQRMAT[ON EVALUATION OF POTENTIAL HAZARDS <br /> I <br /> I. Site Name: An. SIAL �I(.(/ta 1111 C�PLIfI CQ.( 1. Chemicals Hazards 1_ <br /> Address: ( Cl/rQ,11 121—JA [I Carcinogens: IA21. Q)1_ _ /S C�QQYLP�. mcl'\ <br /> i <br /> Contact Person: t � ❑Corrosives: <br /> Phone N: �l ❑Dusts: <br /> Proposed Date of investigation inspmtion: O ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Owes: ()!? /AI �N1Pi <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Rc- cavation ❑PCBs: <br /> ❑Sampling ❑ Boring/Monitoring Well installation ❑Other: <br /> [Hazardous 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: ❑Other(specify): <br /> Evidence of leaks/and 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: °F(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 <br /> ❑Other(specify): Two-way communication CPQ <br /> ❑ <br /> Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑hisects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL q� <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> I�.I Ss•10 <br /> Plan Approved by: Date: <br /> EH 23081(6117/2010) <br />