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O.P4u1N• C _ <br />2.' ENVIRON �✓IENTAL HEALTH 14PARTMENT <br />• Cq�/FO.R t��P SAN JOAQUIN COUNTY Program Coordinators <br />Donna K. Heran, 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 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 <br />GENERAL SITE <br />1. Site Name: /° <br />Contact Person: Y%O <br />Phone #: <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation ❑ UAR Investigation <br />❑ Tank Closure in Place T ape R ai <br />XT;m Pi a Rem ❑ Re -excavation <br />Xmpling C3 Boring / Monitoring Well installation <br />❑ Hazardous Waste inspection ❑ Tiered Permitting inspection <br />4. <br />F� <br />6. <br />Specific Site htfo tion: <br />Tank No.: 9) Tank Capacity: <br />Tank Content: PV q Tank Age: % <br />Other: <br />Release History: <br />Evidence of leaks / soil contamination: YES ❑ NO <br />Documented Groundwater contamination: YES ❑ NO <br />Backgroundnan Pdescription of any previous investigation or incidence: <br />J? �/� <br />Potential Health & Safety Physical Concerns: (✓ all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />IXNoise Sources: <br />LJ Oxygen Deficiency: <br />❑ Excavation (falls, trips, slipping, cave-ins): <br />Handling and Transfer of a Hazardous Substance (fire, explosions, etc.) <br />❑ Confined space entry (explosions): <br />Heavy equipm t (physic I injury, & trauma resulting from moving <br />equipment): 4 / L j <br />❑ Other (specify): <br />7. Anticipated Biological Hazards: <br />❑ Snakes Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (9/15/2010) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />arcinogens: <br />Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />OFlammables: 2 <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />❑ Other: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (Note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided): <br />❑ Combustible Gas/Oxygen Meter <br />❑ Detector Tubes (specify): <br />❑ Photo ionization Detector <br />❑ Organic Vapor Analyzer <br />❑ Other (specify): <br />lone (see below) <br />If monitoring instruments are not used, rationale or activity/area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat <br />® Safety Glasses/Goggles <br />® Steel toed/shank shoes or boots <br />❑ Flame retardant coveralls <br />® Hearing protection <br />❑ Tyvek <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P Cartridge: <br />® Safety vest <br />Two-way communication ff?C>t'e_i <br />❑ Other (specify): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared b'_. Date: —Z <br />Plan Approved by: Date: <br />