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O.p4utN• C <br /> ENVIR N ENTAL HEALTH D R 'ARTMENT <br /> Donna K.Heran,R.E.H. . SAN JOAQUIN COUNTY Program Coordinators <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 IN ATI )N p EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: y C b 'Fofl J( f c— a— 1. Chemicals Hazards <br /> Address: ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: Iq ❑Dusts: <br /> Proposed Date of investigation/inspection: / ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑U a Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Rt-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> �Q Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Ta ik Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Ta A Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> L <br /> El Detector Tubes(specify): <br /> 4. Type of Operation: G1,"� �(� ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Con ems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> ❑Heat or Cold Stress: °F(nigh ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,ca v-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardot s Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL n <br /> 8. Narrative(provide all information which could impact Health and Safety. Plan Prepare6aaz�: <br /> Date. �7 Ili+ <br /> e.g.,power lines,integrity of dikes,terra n,etc.): <br /> — — Plan Appro d by: U_ Date: I <br /> EH 23081 (3/15/2012) <br />