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Y aPA cOt <br /> ENVIRONMENTAL HEALTH APARTMENT <br /> 4c Foo ;p. SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K. Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 1868 E. Hazelton Ave., Stockton, California 95205 Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Jeff Carruesco,R.E.H.S. <br /> Web: www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> Rodney Estrada,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,R.E.H.S. <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: Carcinogens: /11oSen�lafJ'tES <br /> Contact Pe ❑Corrosives: <br /> Phone N: rson: — 06— ❑Dusts: <br /> Proposed Date of investigation/inspectiow 1'J ❑Explosives: <br /> D9 Flammables:'Pi/ 0 <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 /> �\❑..nnS""ampling ❑Boring(Monitoring Well installation ❑Other: <br /> Fp azardous Waste inspection E]Tiered Permitting inspection <br /> /❑Hazardous Materials Business Plan PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other: ❑Detector Tubes(specify): <br /> ❑Photo ionization Detector <br /> 4. Type of Operation: .�f�rf�n 1IU [I Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: �1i one(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ❑D <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& ard Hat <br /> describe) afety Glasses/Goggles <br /> ❑Heat or Cold Stress: °F(high ambient temp.) teel toed/shank shoes or boots <br /> El Noise Sources: me retardant coveralls <br /> ❑Oxygen Deficiency: ❑Hearing protection <br /> >--Zzcavation(falls,trips,slipping,cave-ins): ❑Tyvek <br /> -landling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Respirator: ❑APR ❑SCBA <br /> v A/P Cartridge: <br /> Confined space entry(explosions): [ISafety vest <br /> Ieavy equipment(physical injury&trauma resulting from moving ❑Two-way communication <br /> equipment): ❑Other(specify): <br /> ❑ <br /> Other(specify): <br /> PART IV <br /> T Anticipated Biological Hazards: PLAN APPROVAL <br /> ❑Snakes 1�rinsects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: S 6 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> EH 23081 (4/30/2013) <br />