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PgUtry <br /> ENVI 004ENTAL HEALTH 10PARTMENT <br /> •c4�iFOR��r SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E. S. Kase L.Foley,Director 600 East Main Street, Stockton, California 95202 Y Y•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 INFORMAT ON �A EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: wv e/G t / [Xf 1. Chemicals Hazards.�'Z�%�%�/J/ <br /> Address: 5;5�45 -C, e7 S07—ArdV Carcinogens:, <br /> Contact Person: ❑Corrosives: <br /> Phone#: (& 2 t,�70 ❑Dusts: <br /> Proposed Date of investigation/insp ion: �2 —1? / [I Explosives: /�/J] <br /> ZFlammables: Vr�.�} <br /> ,,�1��//(��/���G[�►(X� <br /> 2. Description and brief narrative of in tion activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑ AR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑ ank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ e-excavation ❑PCBs: <br /> ❑Sampling ❑ oring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑ iered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: I ank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: I ank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination ❑YES ❑NO rolVone(see below) <br /> Documented Groundwater contaminT', ❑YES F1 NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pus investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Coi cems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,caie-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous 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): OTwo-way communication TSL);2,e <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes sects ❑Roden ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information whic could impact Health and Safety, Plan Prepared Y. <br /> Date: <br /> e.g.,power lines,integrity of dikes,tern iin,etc.): I <br /> Plan Approved by: �U Date: <br /> EH 23081 (9/15/2010) <br />