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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna YL Her ,R.E.H.S. Unit Supervisors <br /> W Direr r <br /> 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> z,J Al Olsen E.H.S. $tOCktOri California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> Douglas W.Wilson,R.E.H.S. <br /> C9��FOR�\PProgram A.anager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Cotul la,R.E.H.S. <br /> Program Iv.anager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <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:Mr.ED's MUFFLER&BF AKE 1. Chemicals Hazards <br /> Address:23910 S.DARRIGO DRIVE TRACY CA 95376 <br /> ❑Carcinogens: <br /> Contact Person:ED DEFRENCHI Phone No:(209)836-3914 ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspect n: ❑Explosives: <br /> ®Hammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑U R Investigation. ®Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑R.-excavation. ❑PCB's: <br /> ®Hazardous Waste Inspection. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: T nk Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: Muffler&WeldinK ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: El YES ❑NO El Other,specify. <br /> Documented Groundwater contaminati n: E]YES [I NO if monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pre tious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that appl &describe) ®Hard Hat. <br /> ® <br /> El Hear or Cold Stress: (high ambient temp.) Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury trauma resulting from moving ®Safety vest. <br /> equipment): ®Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodent ❑Poisonous Plants Plan Prepared by: Date: 0 <br /> ®Other/Unknown(specify): <br /> Plan Approved by: zgi Q_ Date: C� <br /> 8. Narrative(provide all information whi(h could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,ten ain,etc.) <br /> UNKNOWN <br /> EH 23081 (12/17/2002) <br />