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o.Pqu�N• c <br /> z ENVIROIRlENTAL HEALTH DEPARTMENT <br /> a: .a <br /> C��%FOFR�`P <br /> Donna K. Heran,R.E.H.S. SAN JOAQUIN COUNTY 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 /> J <br /> Web:www.sjgov.org/ehd effCarruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE IXORMATION a EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: l-77 1. Chemicals Hazards <br /> Address:. A2arcinogens: <br /> Contact Person: f.4d,1 j�n ❑Corrosives: <br /> Phone#: 2X O ElDusts: <br /> Proposed Date of investigation/inspection: 3 D ❑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 /> [I Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> dous Waste inspection E]Tiered Permitting inspection <br /> 1111����'''' 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: ffl, '�+i� ❑Photo ionization Detector <br /> T� ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO IQAbne(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If mon/itoWng 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.) <br /> ®Hard Hat <br /> —aoise Sources: ®Safety Glasses/Goggles <br /> -xygen Deficiency: ®Steel toed/shank shoes or boots <br /> excavation(falls,trips,slipping,cave-ins): El Flame retardant coveralls <br /> ndling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®Hearing protection <br /> / " ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> 'qHeavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> uipment): ®Safety vest <br /> ❑Other(specify): b9awo-way communication <br /> ❑Other(specify): <br /> 7. AnticipateO Biological H ds: <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 by Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ' - _ 1 <br /> Plan Approved by: Date: t <br /> EH 23081 (4/7/2010) <br />