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JO t'4�.pe <br /> ENVIROOIENTAL HEALTH D. ,,eARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> Donne K.Haran,RE H.S. 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. <br /> Director <br /> Telephone:(209)468-3420 Fax (209)468-3433 Robert McClellon,RE.H.S. <br /> Jeff Carruesco,RE.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INTORMA77ON EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: 14 1. Chemicals Hazards <br /> Address Iq S f- b44 Ci ❑Caminogens: <br /> Contact Person: ❑Corrosives: <br /> Phoue#: f1 ❑Dusts: <br /> Proposed Date of investigation/inspection: 2,04 1Z ❑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 ❑TankMVe Repair ❑Oxidizers: <br /> ❑TankTVe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> P,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 ins ri ments 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: AIIM/ ❑Photo ionization Detector <br /> 1 ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO Hmonitoring instruments menot 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 SO <br /> ❑Heat or Cold Stre/ss::1 �7°F(high ambient temp.) ®Hard Hat <br /> Noise Sources: P/AV Ldf4a ®Safety Glasses/Goggles <br /> Oxygen Deficiency:—0 ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cavo-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 /> 10�Heavy equipment(physical minty&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ]Snakes 4 Insectsodcots ❑Poisonous Plants PART IV <br /> 0ther/Udmown(specify: PLAN APPROVAL <br /> ,L <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: M Nadu Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): (`�� � <br /> Plan Approved by: Y Date: <br /> EH 23081(5/62011) <br />