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Pqu rly. <br /> ENVIRON4ENTAL HEALTH DgARTMENT <br /> �.cgC1FORa;P.� SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 Y y> <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 INFORM TION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: / 1. Chemicals Hazards _ <br /> Address: Carcinogens: lQ�� <br /> Contact Person: <br /> '/ n E]Corrosives: <br /> Phone#: �7 2 d L ❑Dusts: <br /> Proposed Date of investigation/inspection: a ❑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 Repairxidizers ,4 , <br /> ❑Tank/Pipe Removal F1Re-excavationPCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation <br /> -XHazardous Waste inspection ❑Tiered Permitting inspection )01 <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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 /> ,r ❑Detector Tubes(specify): <br /> 4. Type of Operation: /v ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: C El Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO I 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: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Xtxcavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Wandling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> //� ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> `ROHeavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest , <br /> E]Other(specify): Y§Two-way communicatiomr'ryr tpt-c— <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> `Snakes 141nsects *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 Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): �i <br /> Plan Approved by: kul <br /> Date: <br /> EH 23081(3/5/2012) <br />