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ENVIRC . .MENTAL HEALTIMEPARTMENT <br /> .+1 <br /> . SAN JOAQUIN COUNTY <br /> �i •..a,�;i�� Donna K.Director R.E.H.S. 304 East Weber Avenue, Third Floor program Coordinators <br /> Directo <br /> Carl Borgman,R.E.H.S. <br /> Huggins,Laurie A.Cotulla,R.E.H.S. Stockton, California 95202 Mike Hu gg' ,R.E.H.S.,R.D.I. <br /> Assistant Director <br /> Telephone: (209) 468-3420 Kasey L.Foley,R.E.H.S. <br /> Margaret Lagorio,R.E.H.S. <br /> Fax: (209).464-0138 Robert McClellon,R.E.H.S. <br /> Web: www.sjgov.org/ehd Jeff Cartuesco,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:AuLQzone 1. Chemicals Hazards <br /> Address: 14W k UT DW D <br /> Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection:January 26.2011 ]Explosives: <br /> g]Flammables: <br /> 2. Description and brief narrative of inspection activity: 4 Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> Q Installation of Borings/Monitoring Wells. <br /> Hazardous waste inspection ❑ Sampling <br /> Tiered Permitting inspection 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: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation: Used oil Collection center/auto parts store ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> []Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ONO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES P NO <br /> Background and description of any previous investigation or incidence: <br /> Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C OD <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: CM HRMg protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): LInTyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, En Respirator: ❑APR ❑SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ED Safety vest. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Two-way communication. <br /> equipment): <br /> ❑other,specify: PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by: Michelle Henry Date: January 24,2011 <br /> ❑Snakes 0 Insects Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): 8A <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />