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EwiRONENTAL HEALTH DAARTMENT <br /> •ej�/FOaa:P' <br /> Donna K. SAN JOAQUIN COUNTY program Coorr/Inators <br /> Director R.E.H.S. 600 East Main Street, Stockton,California 95202 Kaley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Camtesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards J ,,,.,y <br /> Address: Carcinogens: Xk- ,.,29n/ i t�1 <br /> Contact Person: a. ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigatiodinspection: El Explosives: <br /> 'lammables: rw-e , <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases.- <br /> [] <br /> ases:❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation [I PCBs: <br /> 111...❑...,,,,��S��_ampli'''ng C]Boring/Monitoring Well installation C]Other: <br /> iazan ors Waste inspection E]Tiered Permitting inspection <br /> `� PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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: El Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO gone(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 /> �9�Flandlmg and Transfer of a Hazardous Substance(fire,explosions,etc.):. Tk Hearing protection <br /> ❑ <br /> T\ yv <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> W-Heavy equiprgegt(phys. I�'rr, &trauma resulting from moving A/P Cartridge: <br /> equipment): V P.YI.1 GI.= ®Safety vest <br /> ❑Other(specify): Two-way commm icationP�PTLe� <br /> ❑Other(specify): <br /> 7. Anticipated B'oI gical Hazards: <br /> Snakes Insects VRodmts ❑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: S a3 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: <br /> Date: <br /> EH 23081(5/5/2011) <br />