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SAN J <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: SUSD Edison High Schoc <br />Address: 1425 S. Center St., Stockton <br />Contact Person: Butch Schmidt <br />Sweeps Number: <br />Proposed Date of investigation/inspec <br />2. Description and brief narrative of in: <br />❑ New UST installation.. <br />❑ <br />❑ Tank Closure in Place.. <br />❑ <br />❑ Tank/Pipe Removal. <br />❑ <br />❑ Installation of Borings / Monitor <br />® Hazardous waste inspection <br />❑ <br />❑ Tiered Permitting inspection <br />3. Specific Site hrformation: <br />Tank No.: <br />Tank Content: <br />Other: <br />4. Type of Operation: <br />5. Release History: <br />Evidence of leaks / soil contamination: <br />Documented Groundwater contaminati <br />Background and description of any pre <br />6. <br />Potential Health and Safety <br />Physical Concerns: (check all that apply <br />❑ Heat or Cold Stress: °F <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cal <br />❑ Handling and Transfer of a Hazardot <br />etc..): <br />❑ Confined space entry: (explosions): _ <br />❑ Heavy equipment (physical injury & <br />equipment): <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents <br />❑ Other/Unknown (specify): <br />ri <br />r <br />COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE HEALTH AND SAFETY PLAN <br />Phone No: 933-7045 <br />>n: May 2007 <br />:tion activity: <br />\R Investigation. <br />nk/Pipe Repair. <br />-excavation. <br />Wells. <br />unpling <br />ilk Capacity: <br />nk Age: <br />❑ YES ❑ NO <br />❑ YES ❑ NO <br />investigation or incidence: <br />describe) <br />gh ambient temp.) <br />Substance: (fire, explosions, <br />resulting from moving <br />❑ Poisonous Plants <br />8. Narrative (provide all information which tould impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrai4, etc.) <br />EH 23081 (02/19/03) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />® Carcinogens: Lab Waste, Photo Waste_ <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />❑ Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />❑ Two-way communication. <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: Ray von Flue Date: 5/2/07 <br />Plan Approved by: Date: <br />