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oPqu{.N.• c <br /> ENVIRID, IENTAL HEALTH DEPARTMENT <br /> •c��iFcaa�� SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Henan,R.E.H S. <br /> Director 600 East Main Street, Stockton, California 95202 Kase Y L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Falx. (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 I ORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: _-G-Carcinogc �S�[' 1 GV►1.11 l)L{�j <br /> Contact Person: k4 '1 ' L) F1 Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspect on: �� ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of' tion activity: ❑Inorganic Gasels,:' n <br /> ❑New UST installation ❑ Investigation E'Metals: I-n- (Y. <br /> ❑Tank Closure in Place ❑T Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ -excavation ❑PCBs: <br /> ❑Sampling ❑B ring/Monitoring Well installation ❑Other: <br /> `C?Hazardous Waste inspection ❑T erect Permitting inspection <br /> — PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Taik Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: T k Age: operations unless appropriate rationale or restrictions are provided): <br /> Other.: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: <br /> C3 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 Co ems:(✓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,caa-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardois 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): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑ Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information whicl i could impact Health and Safety, Plan Prepared by: tine! =7 Date: ^� <br /> e.g.,power lines,integrity of dikes,tern in,etc.): <br /> Plan Approved by: Date: 4` <br /> EH 23081(5/9/2011) <br />