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a�aury c <br /> .: <br /> ENVI ON ENTAL HEALTH MPARTMENT <br /> SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Heran,R.E.II.S. <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 /> Jeff Carruesco, R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte, R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: -it` d ❑Carcinogens: <br /> Contact Person: rE7tr C ❑Corrosives: <br /> Phone#: (v ❑Dusts: <br /> Proposed Date of investigation/ins tion: Z 6--/t ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of in ction activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑ ank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ e-excavation ❑PCBs: <br /> ❑Sampling ❑ oring/Monitoring Well installation ❑Other: <br /> ,QCtS4zardous Waste inspection ❑ iered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: ank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: ank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: r ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contaminatio ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamina ion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any vious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Cc ncerns:(✓all that apply&describe) bevel of Protection: ❑A ❑B ❑C ®D <br /> ❑Heat or Cold Stress: (high ambient temp.) <br /> ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping, ve-ins): ❑Flame retardant coveralls <br /> dandling and Transfer of a H . us Substance(fire,explosions,etc.):. ®Hearing protection <br /> G. 4, ❑Tyvek <br /> ElConfined space entry(explosions): [I Respirator: [I APR [I SCBA <br /> [ lleavy equipment(physical injury trauma resulting from moving A/P Cartridge: <br /> II <br /> l �.. ®Safety vest <br /> equipment):_ <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Roden ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL j. <br /> 8. Narrative(provide all information whi h could impact Health and Safety, Plan Prepared Date? 2,6 /t <br /> e.g.,power lines,integrity of dikes,to in,etc.): <br /> U f Z7 <br /> Plan Approved by: y <br /> {\' � Date: <br /> EH 23081(7/26/2011) <br />