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0 <br />HEALTH*DEPARTMENT <br />ENVIRONMENTAL <br />DVN <br />X02 SAN JOAQUIN COUNTY <br />=>°P <br />Unit Supervisors <br />a 1 Donna K. Heran, R.E.H.S. <br />304 East Weber Avenue, Third Floor <br />man, <br />Carl Bor man, R.E.H.S. <br />Borg <br />Director <br />Olsen, R.E.H.S. Stockton, California 95202-2708 <br />Mike Huggins, R.E.H.S., R.D.I. <br />Douglas W. Wilson, R.E.H.S. <br />cq.... aP Program Manager Telephone: (209) 468-3420 <br />� <br />Margaret Lagorio, R.E.H.S. <br />i F o R Laurie A. Cotulla, R.E.H.S. <br />Fax: (209) 464-0138 <br />Robert McClellon, R.E.H.S. <br />Program Manager <br />Mark Barcellos, R.E.H.S. <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: Safeway Distribution Center I . Chemicals Hazards <br />Address: 16900 E. Schulte Road, CA ®Carcinogens: <br />Contact Person: Mike Dysinger Phone No: (09) 833-4960 ❑ Corrosives: <br />Sweeps Number: ® Dusts: <br />Proposed Date of investigation/inspection: February 13, 2004 ❑ 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. ❑ Tank/Pipe Repair. ❑ Oxidizers: _ <br />❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ PCB's: <br />_ <br />❑ Installation of Borings / Monitoring Wells. <br />® Hazardous Waste Inspection ❑ Sampling. PART III <br />3. <br />Specific Site Information: <br />Tank No.: _ Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: Warehouse / maintenance <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: °F (high ambient temp.) <br />® Noise Sources: EQUIPMENT <br />❑ Oxygen Deficiency: _ <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): UNKNOWN <br />EH 23081 (12/17/2002) <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />I. 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 />0 Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />® Two-way communication <br />PART IV - PLAN APPROVAL �f <br />Plan Prepared b : Date: <br />Plan Approved by: Date: / <br />