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).•`�. !IV '•.per <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Y c*<<F�•R�`r• � <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY Prograin Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L. Foley,R.E.H.S. <br /> Telephone: (209)468-3420 Far: (209) 468-3433 Robert McClellon, R.E.H.S. <br /> JeffCarruesco,R.E.H.S. <br /> Web: www.sjgov.org/ehd <br /> SITE HEALTH & SAFETY PLAN <br /> PART I PART I1 <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1, Site Name: I. Chemicals Hazards <br /> Address: 1 r Carcinogens: <br /> Contact Person: S ❑Corrosives: <br /> Phone#: S�'2 at V ❑Dusts.- <br /> Proposed <br /> usts:Proposed Date of investigation/inspection:_] ,'110 0 Explosives: <br /> r <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ 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 /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART I11 <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. Monitoring Equipment(Note:Monitoring instruments must 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: I ❑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&Safe7 Physical Concerns:(�/all that apply&describe) Levet of Protection: ❑A ❑B ❑C ED <br /> ❑Heat or Cold Stress: °F(high ambient temp.) <br /> ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: Steel toed/shank shoes or boots <br /> Excavation(falls,trips,slipping,cave-ins): <br /> ❑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(ph sicaI ina &trauma resulting from moving AIP Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): $ZTwo-way communication/ I <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Snakes �[hrsects Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Preparedb ate: Ot ff1 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): r // <br /> Plan Approved by: Y Date. <br /> EH 23081 (8/6/2010) <br />