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v soPq�!N^.co2 <br /> ENVIROT�AENTAL HEALTH D ARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> rlFoa`r 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 Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEAL'T'H&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO TION EVALUATION OF POTENTIAL HAZARDS <br /> GENERAL SITE INF0§nON <br /> 1. Chemicals Hazards J^ <br /> 1. Site Name: <br /> Address: b Q Carcinogens: <br /> Contact PeAlp <br /> rson _ErCorrosives: <br /> Phone#: _01Dusts: 1 t <br /> Proposed Date of investigafion/inspection: El Explosives: <br /> ❑Flammebles: <br /> 2. Description and brief narrative of inspection activity: <br /> _L31norganic Goes:n rAl"' D,f-0 7 <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 /> azardous Waste inspection ❑Tiered Permitting inspection <br /> PART IH <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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: <br /> � �� ❑Detector Tubes(specify): <br /> ❑Photo ionization Detector <br /> 4. Type of Operation, �t9,.Q11'fl"A)LJf -L�M� <br /> ❑Organic Vapor Analyzer <br /> ❑other(specify): <br /> 5. Release History: ❑None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> if monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES F-1 NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: El A El B El C ®D <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Hat <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: <br /> ❑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): Alp Cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> El PLAN APPROVAL Other/Unknown(specify): �/� <br /> 8. Narrative(provide all information which wind impact Health and Safety, Plan Prepared by: <br /> Date: � �� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): U <br /> Plan Approved by: 4•� _ Date:1 <br /> EH 23081(6/142012) <br />