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c aaPa .cey� <br /> ENVIRONTVIENTAL HEALTH D ARTMENT <br /> •.c'gFiPdAa(p• SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.H rector R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 y y, <br /> Telephone: (209)468-3420 Fav (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 PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> t <br /> 1. Site Name:_ i� ;tW o 5 'G* 'IT <br /> L Chemicals Hazards <br /> Address: moi' �i�-e.. .. ❑Carcinogens: <br /> Contact Person:��',ar w^' o C]Corrosives: <br /> Phone N: — I L)5;2 - ❑Dusts: <br /> Proposed Date of investigationlinspection: ❑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 /> y, ' ardous 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Opemtion:—A— -0�0 >/" ❑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:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C E D <br /> ❑Heat or Cold Stress: IF(high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glmses/Goggles <br /> [I Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> E]Excavation(falls,trips,slipping,cave-ins): [I Flame retardant coveralls <br /> ,L39-landling and Transfer of a Hazardous Substance(fire,explosions,etc.):_ E Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> �+Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL ^7 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date?/y /:t- <br /> e.g., <br /> Y <br /> e.g.,power lines.integrity of dikes,terrain,etc.): _ '//� ,'l/!1� I r <br /> ------ 12, <br /> Plan Approved 1`L) 1 Date: J I <br /> EH 23081(3/152012) <br />