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Op4u,x C ' <br /> 2' ENVIRONENTAL HEALTH DARTMENT <br /> • Cq�IFpRN;P.• SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Her•an,R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y y, <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO TIONff , EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: l � 1. Chemicals Hazards <br /> Address: 4 Carcinogens: <br /> Contact Person: XrCorrosives: <br /> Phone#: 'Dusts: <br /> Proposed Date of investigation/inspection:_ explosives: <br /> �Flammables: <br /> 2. Description and brief narrative of inspection activity: organic 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 /> az dous Waste inspection El Tiered Permitting inspection <br /> W(wc V-1P- PART III <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 /> t� ❑Detector Tubes(specify): <br /> 4. Type of Operation:- 4(. 1' ❑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 contaniination: ❑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 ®D <br /> ❑Heat or Cold Stress: 1r� IF(high ambient temp.) ®Hard Hat <br /> oise Sources %t7l IQ�fiti V Yr�N1� ®Safety Glasses/Goggles <br /> Steel toed/shank shoes or boots <br /> Oxygen Deficiency: <br /> El Flame retardant coveralls <br /> IDExcavation(falls,trips,slipping,cave-ins): <br /> ®Hearing protection <br /> E]Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> \VI)Heavy equip t by Ica l injury&trauma resulting from moving A/P Cartridge: <br /> "quipment): ®Safety vest <br /> El Other(specify): [ITwo-waycommunication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> S. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Date:— <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: V Date: 2 <br /> EH 23081(6/1412012) <br />