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ENVIRO NTAL HEALTH ^ARTMENT <br /> • �4�+Fo :P• <br /> Donna K.Heron,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 K.asey L,Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Catruesco,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 INFORMATION ' � EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: SS��sL� G1 /�`7�"C aV r- 1. Chemicals Hazards f <br /> Address: 1,32- XCarcinogens:fll! f anlrrPze' <br /> Contact Person: ❑Corrosives: <br /> Phone#: Dusts: <br /> Proposed Date of investigation/inspection- / '� ❑Explosives: <br /> 0 Flammabies: TT _ <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: C'A�f 2F'.f't <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring well installation ❑Other: <br /> XI-lazardous Waste inspection ❑Tiered Permitting inspection <br /> 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 /> F]Detector Tubes(specify): <br /> 4. Type of Operation: / ! L �1 C/ V i ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO lone(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:(✓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 /> �acavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ndling and Transfer of a Hazardous Substance(fire,explosions,etc.): ❑Hearing protection <br /> Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> (Hcavy equipment(physical injury&trauma resulting from moving A/P Cartridge: _ <br /> equipment): Safety vest <br /> ❑Other.(specify): ATwo-way communication F�7 00 6 <br /> ❑Other(specify): <br /> 7. %icipated Biological Hazards: <br /> nakesInsects odents ❑Poisonous Plants PART IV <br /> Fl Other/Unlarown(speer ): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepar Date: /r 2V !� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: Z1]b <br /> EH 23081(9/15/2010) <br />