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y ENVIRONMENTAL HEALTH DEPARTMENT <br /> • eP SAN JOAQUIN COUNTY Program Coordinators <br /> 4�lF°"a Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 1868 E. Hazelton Ave., Stockton, California 95205 Robert McClellon,R.E.H.S. <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Jeff Carruesco,R.E.H.S. <br /> Web: www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> Rodney Estrada,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,R.E.H.S. <br /> PART I PART II <br /> GENERAL SITE INFOPMATION EVALUATION OF POTENTIAL,HAZARDS <br /> 1. Site Name: I. Chemicals Hazards <br /> Address: '� Carcinogens:C� <br /> Contact Person: t�3Corrosivcs:"O , 610y a Cd <br /> Phone 4: "J ❑Dusts: /� <br /> Proposed Date of investigation/inspection: '❑Explosives: nn Nnt . eta YV <br /> Flammables: [l call[�15.. 0.CtiYiF .Cl Cl�v4x PA i Q ( DGL1 t�. <br /> 2, Description and brief narrative of inspection activity: Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation 'Metals: fi ,Q.-13) <br /> Tank Closure in Place ❑Tank/Pipe Repair ":ROxidizcrs:TV_C40,01 <br /> ❑Tank/Pipe Removal ❑Re-excavation PCBs: w <br /> ampling ❑Boring/Monitoring Well installation Other: 01 1 1ALWkM <br /> azardous Waste inspection ❑Tiered Permitting inspection <br /> ❑Hazardous Materials Business Plan PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other; ❑ Detector Tubes(specify): <br /> ❑ Photo ionization Detector <br /> 4. Type of Operation: ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment LA <br /> Level of Protection: ❑A ❑B ❑C <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& "Poard Hat <br /> describe) Safety Classes/Goggles <br /> ❑Heat or Cold Stress: IF(high ambient temp.) teel toed/shank shoes or boots <br /> Oise Sources: ❑Flame retardant coveralls <br /> Oxygen Deficiency: caring protection <br /> ❑Excavation(falls,trips,slipping,cave-ins): 'LJ t yvck <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ❑Respirator: ❑APR ❑SCBA <br /> A/P Cartridge: <br /> ❑Confined space entry(explosions): ❑Safety vest <br /> Meavy equipment(physical injury&trauma resulting from moving ❑Two-way communication <br /> equipment): ❑Other(specify): <br /> ❑Other(specify): <br /> PART IV <br /> 7. Anticipated Biological Hazards: PLAN APPROVAL <br /> ©Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> E] :Other/Unknown(specify): Plan Prepared b Date: 1�I r3 <br /> 8. Narrative(provide all information which could impact Health and Saflety, Plan Approved by: Date`�� <br /> e.g„power lines,integrity of dikes,terrain,etc.): <br /> EH 23081(1/2/2013) <br />