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ENVIRONMENTAL HEALTH ]DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna Heran,RE.H.S.cl <br /> Unit Supervisors <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> 1 ``4 Al Olsen,R.E.H.S. Stockton California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> Douglas W.Wilson,R.E.H.S. <br /> Prc gram Mar agerTele hone: 209 468-3420 Margaret La orio R.E.H.S. <br /> �iFoa Laurie L.Co R.E.H.S. Fax: (2 9)464-0138 Robert McC ellon,R.E.H.S. <br /> Pr am Mar ager Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Park Avenue Cleaner 1. Chemicals Hazards <br /> Address:1296 W.I I'b St.Tracv.CA 9f 376 <br /> ®Carcinogens: <br /> Contact Person:Gurte•Brar Phone No:(209)602-7038 ❑Corrosives: <br /> Sweeps Number: <br /> ®Dusts: <br /> Proposed Date of investigati /inspection:February 20,2004 ❑Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑U R Investigation. ®Metals: <br /> ❑Tank Closure in Place. ❑Ta k/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ®Hazardous Waste Inspection ❑Sa npling. PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Taiik Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tk Age: <br /> operations unless appropriate rationale or restrictions are provided) <br /> _ <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:Cleaner ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of leaks/soil conti urination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description f any prev ous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ZD <br /> 6. Potential Health and Safety Z Hard Hat. <br /> Physical Concerns:(check al that apply&describe) ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F I high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Flame retardant coveralls. <br /> ®Noise Sources: EQUIPM ENTEQUIP <br /> El Oxygen Deficiency: ®Hearing protection. <br /> ❑Tyvek. <br /> ❑Excavation:(falls,trips,slipping,ca -ins): <br /> ❑Respirator: El APR ❑SCBA <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> A/P cartridge: <br /> etc..): <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> ❑Heavy equipment(physical injury& uma resulting from moving ®Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL n <br /> 7. Anticipated Biological Hazar, s: Plan Prepared by Date: 74( <br /> ❑Snakes ❑Insects Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify) Plan Approved by: Date: <br /> 8. Narrative(provide all info tion which could impact Health and Safety, <br /> e.g.,power lines,integrity of likes,terrain,etc.):UNKNOWN <br /> EH 23081(12/17/2002) <br />