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IK.Cak <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> F0 Program Coordinators <br /> qp Donna YL Heran,R.E H.S. <br /> Director 1868 E.Hazelton Ave., Stockton,California 95205 Kase 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 /> PARTI PARTH <br /> GENERAL SIT INFO TI N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site NamVe: ,0­ 1. Chemicals Hazards <br /> Address: rn 0 Carcinogens:.. & "hiableelf <br /> P V. <br /> Contact Person: n rD /I ❑Corrosives: <br /> 0 <br /> Phone#: Dusts: <br /> I mi/m.,p ti I El Explosives: <br /> Proposed Date of inves' atii ny/i tion: <br /> ❑Flammables: <br /> 2. Description and brief narrative of in pection activity: El Inorganic Gases: <br /> 0 New UST installation El UAR Investigation El Metals: <br /> D Tank Closure in Place El Tank/Pipe Repair D Oxidizers: <br /> F1 Tank/Pipe Removal El Re-excavation El PCBs: <br /> El Sampling E]Boring/Monitoring Well installation n Other: <br /> razardous Waste inspection E]Tiered Permitting inspection PART HI <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: —,Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: El Combustible Gas/Oxygen Meter <br /> 0 Detector Tubes(specify): <br /> 4. Type of Operation: +W Imil E]Photo ionization Detector <br /> El Organic Vapor Analyzer <br /> 5. eleU <br /> —'Orb F-1 Other(specify): <br /> '1� <br /> Evidence of leaks/soil contaminate c ri: El YES F-1 NO [I None(see below) <br /> Documented Groundwater contamin ion: []YES n NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any p evious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical C)ncems:(Y/all that apply&describe) Level of Protection: [IA [IB El C OD <br /> 0 Heat or Cold Stress: F(high ambient temp.) E Hard Hat <br /> 0 Noise Sources: E Safety Glasses/Goggles <br /> El Oxygen Deficiency:_ 0 Steel toed/shank shoes or boots <br /> E]Excavation(falls,trips,slipping,,ave-ins): F1 Flame retardant coveralls <br /> E]Handling and Transfer of a Hazar lous Substance(fire,explosions,etc.):. 0 Hearing protection <br /> E]Tyvek <br /> El Confined space entry(explosions El Respirator: El APR El SCBA <br /> El Heavy equipment(physical injui) &trauma resulting from moving A/P Cartridge: <br /> equipment):— 0 Safety vest <br /> El Other(specify):— El Two-way communication <br /> El Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> El Snakes El Insects El Roder is El Poisonous Plants PART IV <br /> El Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information wh ich could impact Health and Safety, Plan Prepared by:—11-�A 3� C' Date: <br /> e.g.,power lines,integrity of dikes,te rrain,etc.): <br /> Plan Approved by: L) 1 Date: <br /> EH 23081(8/14/2012) <br />