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OPQ��N. C <br /> •% ENVIRO N ENTAL HEALTH �eARTMENT <br /> Cq�iFpl+a�f• SAN JOAQUIN COUNTY <br /> Donna K.Heran,R.E.H.S. 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 Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO ATIO EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: 1. Ch cats Hazards <br /> Address: 4 carcinogens: 61 I <br /> Contact Person: U [(Corrosives: NAM , ficliG t AIRItkolf <br /> Phone#: (104, P 3 >� ' <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: I l ❑Explosives: <br /> [glammables: 19 <br /> 0 <br /> -1 <br /> 11t <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: 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 /> t� <br /> [3 Detector Tubes(specify): <br /> 4. Type of Operation: A�t a u e � ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: YES ❑NO Ione(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: Z Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> xcavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> andling 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): bR t'wo-way communication pr ltrC <br /> �Q Other(specify): <br /> 7. Anticipated Biological H ds: <br /> Snakes sects odents ❑Poisonous Plants PART IV <br /> ❑Other/U own(sl <br /> ): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b te: �/� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH 23081(5/5/2011) <br />