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'Ck w N <br /> Q '0` c ENVIRG_ .MENTAL HEALTI. . DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> cq ., �° Donua K.Reran R.E.H.S. Program Coordinators <br /> �rFoeet 304 East Weber Avenue,Third Floor Carl Borginan,R.E.H.S. <br /> Director Huggins,R.E.H.S.,R.D.I. <br /> Laurie A.Cotulla,R.E.H.S. Stockton, California 95202 Mike Hu <br /> Assistant Director Telephone: (209)468-3420 Kasey L.Foley,R.E.H.S. <br /> Margaret Lagorio,R.E.H.S. <br /> Fax: (209).464-0138 Robert McClellon,R.E.H.S. <br /> Web: www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION <br /> _ � S EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: WO l4 Carcinogens: <br /> Contact Person: one No: '9;T—-76 7 q ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: �?u <br /> Explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ElNew UST installation.. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ElTank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> Hazardous waste inspection ❑ Sampling PART III <br /> Tiered Permitting inspection <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: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation: 600 ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑ NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glassestgoggles. <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> [I Oxygen Deficiency: ®Hearing protection. <br /> C]Excavation:(falls,trips,slipping,cave-ins): El Tyvek. <br /> ❑ <br /> C3 Handling and Transfer of a Hazardous Substance:(fore,explosions, El Respirator: El APR SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify: PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by: M Naidu Date: 2, <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: 2� 1 Date: v <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />