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soPgplp <br /> NCCN 2� <br /> ENVIRO NTAL HEALTH D ARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> '�7koR Donna K.Heran,R.E.H.S. Kasey L.Foley,RE.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 Carrawco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> STTE HEALTH&SAFETY PLAN <br /> PARTI PART R <br /> GENERAL SITE ORMATION�L EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: r�—el7� a" 1. Chemicals Hazards <br /> Address: V✓� ❑Carcinogens- <br /> Person:Person: �t ❑Corrosives: <br /> Phone#: ��S ✓ ❑Dusts: <br /> Proposed Date of investigationlinspection: ❑Explosives: <br /> tp 'lammables <br /> 2. Description and brief narrative of inspection activity: ❑Inorgamic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Mils: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers. <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> �❑,`S'ampling ❑Boring/Monitoring Well installation ❑Other: <br /> pdtfazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: I REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Age- operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: g ' ❑Combustible Gas/Oxygen Meter <br /> Other: <br /> ❑Detector Tubes(specify): <br /> ^ ❑Photo ionization Detector <br /> 4. Type of Operation: ,y ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: NO None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> 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 /> Level of Protection: ❑A ❑B ❑C OD <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Ha[ <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> y❑Excavation(falls,trips,slipping,cavc-ins): ®Hearing protection <br /> f XHandling and Transfer of a Hazardous Substance(fire,explosions,etc.); ❑Tyvek <br /> TTT VVV ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> sEy(,,l,`eavy equipment(p icpl ury&trauma resulting from moving ®Safety vest <br /> t equipment): .e' 'ate ' phayLv , <br /> ❑Other(specify): 0 Other <br /> communication <br /> ther(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes Insects El Rodents ❑Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by:,!V <br /> (r( <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Date: 1 V <br /> Plan Approved by: <br /> EH 23081(3/52012) <br />