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Pqury <br /> z ENVIRON ENTAL HEALTH D PARTMENT <br /> -.a;� SAN JOAQUIN COUNTY Program Coordinators <br /> �iFoa 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 INFORMATION � � ^ , EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: `��1�� �(«1 +C C/� 1. Chemicals Hazards <br /> Address: Iq-7-77-1 lit.1 V l_eAL)1 S—'Ll-. carcinogens:81�_ �► � � <br /> Contact Person: ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: W `2 1 ❑Explosives: <br /> -tg�Fiammables: A-t-2h4Cmp, (�U <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gas <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair "ZOxidizers: ?X14(rein <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> 't,.�azardous 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 /> c' .\, ❑Detector Tubes(specify): <br /> 4. Type of Operation: L 1 T lam- ❑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 ®D <br /> ❑Heat or Cold Stress: IF(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,cave-ins): ❑Flame retardant coveralls <br /> �Iandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> [MConfined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> eavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): 5R�rwo-way communication Ph pnQ_ <br /> ❑Other(specify): <br /> 7. Anticipated Biological 1-14ds: <br /> ''Snakes (sects odents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> �28. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: Itl <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: �� Date: <br /> EH 23081(5/5/2011) <br />