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y� ENVIROAENTAL HEALTH APARTMENT <br /> w < <br /> SAN JOAQUIN COUNTY program Coordinators <br /> �tFOp� Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Jeff Canttesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE I��ORRMA ION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1 U I IfPur 1. Chemicals Hazards <br /> Address: Int p -a" _ _ ❑Carcinogens: <br /> ,./ <br /> Contact Person: XCorrosives: <br /> Phone#: �YDusts. <br /> Proposed Date of investigationhnspectirm 7❑I Explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: 9 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 /> ' EHazyrdous Waste inspection ❑Tiered Permitting inspection <br /> �LfnlWW(C'11�f1��/ PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: L Monitoring Equipment(Note:Monitoring instruments most be used for all <br /> Tank A e operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: g <br /> ❑Combustible Gas/Oxygen Meter <br /> Other: ❑Detector Tubes(specify): <br /> ��p�btr f i�(� 1 f W C]Photo ionization Detector <br /> 4. Type of Operation:. F`"'VV SIA <br /> ❑Organic Vapor Analyzer <br /> ❑ <br /> Other(specify): <br /> 5. Release History: ❑None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring ins[nunents are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: C]YES []NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A El B C]C OD <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Flat <br /> Heat or Cold Stress: OF(high ambient temp') ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation(falls,trips,slipping,cave-ins): ®Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> b(J Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> `equipment): <br /> ❑ <br /> ❑Other(specify). Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated B7ogical Hazards: <br /> ❑Snakes Insects Rodents ❑Poisonous Plants PART IV <br /> kJX <br /> ❑Other/Unlmown(specify): PLAN APPROV Dale: <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: <br /> Am e.g.,power lines,integrity of dikes,terain,etc.): �/!�� <br /> Plan Approved by: V - Date: ` <br /> EH 23081(6/42010) <br />