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a <br /> o Pqu 1 N••.c �,,,� <br /> �.••�:.rtra o <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • {'�IFORNi4• <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 1868 E. Hazelton Ave., Stockton, California 95205 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 R6bert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.5jgov.org/chd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART] PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:40thJ3Z-f9itrff4ff dl'G 40 f {� 5Q/29 y 1. Chemicals Hazards <br /> Address: 1412 Carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: Dec 13, 2012 ❑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 Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> ❑Hazardous Waste inspection ❑Tiered Permitting inspection <br /> ®Hazardous Materials Business Plan 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑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:(check al l that apply& Level of Protection; ❑A ❑B ❑C ❑D <br /> describe) ❑Hard Hat <br /> t ❑Heat or Cold Stress: °F(high ambient temp.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.), ❑Tyvek <br /> ❑Respirator; ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving (3 Safety vest <br /> equipment): <br /> ❑Two-way communication <br /> ©Other(specify): ❑Other(specify): <br /> 7. Anticipated Biological Hazards: PART 1V <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): L'Y� <br /> Plan Prepared by' Mike Pari38i Date: QeH,2012 <br /> S. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: 0.4 Date: <br /> EH 23081(8121/2012) <br /> 3 <br /> t <br />