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P41u 1!'!. <br /> �Q.4.CQ <br /> 2 z ENVIRO ENTAL HEALTH DARTMENT <br /> RCRa;P.� SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.Heran,R.E.H.S. <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'FAAO/ ATION /� EVALUATION OF POTENTIAL HAZARDS <br /> y <br /> 1. Site Name: 1.t1'` >� 7-"L!A Z4� 1. Chemicals Hazards <br /> Address: i Carcinogens:/ejJ� �'J7f7J <br /> Contact Person: ❑Corrosives: <br /> Phone#: 5 3K Dusts: <br /> Proposed Date of investigation/inspection: Explosives: p <br /> 1XFlammables:'4r' = SLI Z4Z , <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:Ca'CW <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 /> �^ , / <br /> El Detector Tubes(specify): <br /> 4. Type of Operation: / /u Gam/ ❑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 Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Hxcavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Respirator: E]APR F]SCBA <br /> F1 Confined space entry(explosions): <br /> eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> uipment): ®Safety vest <br /> ❑Other(specify): b32fwo-way communication ph,,7W P✓ <br /> ❑Other(specify): <br /> 7. Anticipated Biological H ds: C3 <br /> (akes sects Rodents Poisonous Plants PART IV <br /> Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b . e: �O <br /> e.g.,power lines,integrity of dikes,terrain,etc.): L-),-Plan Approved by: U� Date: s <br /> EH 23081(3/5/2012) <br />