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¢0 u i N :< l.r <br /> �0.. �.• ?y <br /> ENVIRO ENTAL HEALTH D ARTMEN"T <br /> SAN JOAQUIN COUNTY program Coordinators <br /> 4ir�OR� Donna K.Heran,R.E.H.S. <br /> 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R,E H.S. <br /> Director 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 /> ,SITE HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFOIWAT11YON EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards I <br /> Address:� )KCarcinogens:-6rk. 61�as <br /> Contact Person: r&��� ❑Corrosives: <br /> Phone#: '( lto -0/&eG} ❑Dusts- <br /> Proposed Date of investigationlinspection: "I " ❑Explosives: <br /> Hammables: r � <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UA.R Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling [I Boring/Monitoring Well installation Other: ,t✓,�jt ��itlJ �7�GY'D�i .Ll1I/�r� <br /> `/Hazardous Waste inspection C]Tiered Permitting inspection�� 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 au <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:(✓all that apply&describe) Level of Protection: ❑A OB ❑C ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) Z Hard Hat <br /> Z Safety Glasses/Goggles <br /> Oise Sources: <br /> ] xygen Deficiency: E Steel toed/shank shoes or boots <br /> ❑Flame retardant coveralls <br /> xcavation(falls,trips,slipping,cave-ins): <br /> ®Hearing protection <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. <br /> ❑Tyvek <br /> El Respirator: ©APR ❑SCBA <br /> ❑Confined space entry(explosions): A/p Cartridge: <br /> Meavy equipment(physical injury&trauma resulting from moving <br /> equipment): ®Safety vest <br /> ❑Other(specify): Wrwo-way communicatio0rn-10— <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Knakessects Rodents C]Poisonous Plants PART IV <br /> F]Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepar Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.):_ <br /> Plan Approved by: Date: <br /> EH 23081(3/92012) <br />