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PqurN <br /> ENV RONMENTAL HEALTH DEPARTMENT <br /> ORa Donna K.Heran,RLE.H.S. 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 <br /> SITE HEALTH & SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATIO EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site NameI< 1. Chemicals Hazards <br /> Address: U0 6 ` Sfi ❑Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: %G)'l Dusts: <br /> Proposed Date of investigation/' pection: ❑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 ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <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.: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: LLA" t 0 ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contaminati n: ❑YES F1 NO ❑None(see below) <br /> Documented Groundw er conta ation: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and descri tion of any revious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safe Physical oncems:(✓all that apply&describe) Level of Protection: ❑A E)B [3C ®D <br /> El Heat or Cold Stress:fr F(high ambient temp.) ®Hard Hat <br /> E)Noise Sources: ®Safety Glasses/Goggles <br /> C3 Oxygen Deficiency: El Steel toed/shank shoes or boots <br /> F1Excavation(falls,tri s,slipping, ave-ins): ❑Flame retardant coveralls <br /> El Handling and Transfer of a Haza dous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions: ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(p ical inju &trauma resulting from moving <br /> 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): j PLAN APPROVAL <br /> 8. Narrative(provide all information wh ch could impact Health and Safety, Plan Prepared by: '� .�_ i�t._��� Date: <br /> e.g.,power lines,integrit�of dikes,telrain,etc.): <br /> Plan Approved by: Date: I <br /> EH 23081(8/6/2010) <br />