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'O PgU1N.. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> "cam' <br /> Donna K.Haran,RE.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> q Gicoa �P Director 600 East Main Street, Stockton,California 95202 Kase y L.Foley,R.E.H.S. <br /> llo <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert M ruesc , R.H.S. <br /> Jeff Cammesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards11 <br /> Address: ,2CarcinogensMW k C4 l I &V-*1 P <br /> Contact Person: ❑Corrosives: <br /> Phone#: gal Dusts: <br /> Proposed Date of inveatigation/inspeetion: ❑Explosives: <br /> ❑F7ammables: Q��..�,�.�p� <br /> 2. Description and brief narrative of inspection activity: �(Inorganic Gases•T/.I[D I Wd6n�b <br /> ❑New UST installation ❑UAR Investigation ❑Metals:_kt/�,lh' �• <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> fl Hazardous Waste inspection ❑Tiered Permitting inspection <br /> .7 PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments most be used for all <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: 4YIA LL N n;r ❑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 ❑B ❑C OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) E Hard Hat <br /> Cl Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.).. E Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date: 10A 1,01. <br /> e.g.,power limes,integrity of dikes,remain,etc.): <br /> Plan Approved by: 01 Date: <br /> EH 23081(5/92011) <br />