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o.P4ulM• C <br />Q: <br />cq�iFoaa�p <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />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 McCiellon, 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 <br />GENERAL <br />1. Site Na <br />Contact Person: <br />Phone #: --?I; <br />Proposed Date of <br />Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ UAR Investigation <br />❑ Tank Closure in Place <br />❑ Tank/Pipe Repair <br />❑ Tank/Pipe Removal <br />❑ Re -excavation <br />❑ Sampling <br />❑ Boring/ Monitoring Well installation <br />Tlazardous Waste inspection ❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age:_ <br />Other: <br />4. Type of Operation: K & � )w�l�Dl <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. �otertial Health & Safety Physical Concerns: (✓ all that apply & describe) <br />eat or Cold Stress: ✓�I(,�pi �/1�`a(high ambient temp.) <br />/❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />`(MExcavation (falls, trips, slipping, cave-ins): f� <br />Handling and Transfer of a Hazardous Substance fire, explosions, etc.):. <br />Confined space entry (explosions): W as <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other (specify): <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />I <br />emicals Hazards <br />Carcinogens: <br />Corrosives: <br />Dusts: <br />Explosives: <br />Flammables: <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 />❑ None (see below) <br />If monitorin 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 <br />❑ Other (specify): <br />7. Anticipatedi ogical Hazards: <br />makes Insects ?fi)Rodents )'oisonous Plants PART IV <br />❑ Other/Unknown (specify): 1!iG h W 511V�fD �, S PLAN APPROVAL <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (6/14/2012) <br />1J6 GeA <br />Plan Prepared by: " Date: (Od l <br />(D Zjg IZ <br />Plan Approved by: lJ Date: <br />