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aP.4�1N. <br />ENVIROWlENTAL HEALT EPARTMENT <br />❑ UAR Investigation. <br />❑ Tank Closure in Place.. <br />❑ Tank/Pipe Repair. <br />• • <br />'` <br />SAN JOAQUIN COUNTY <br />❑ Installation of Borings / Monitoring <br />P. <br />�.. <br />qui Fiiai'v <br />Donna K. Heran, R.E.H.S. 304 East Weber Avenue, Third Floor <br />Program Coordinators <br />Carl Borgman, R.E.H.S. <br />Tiered Permitting inspection <br />Director <br />Laurie A. Cotulla, R.E.H.S. Stockton, California 95202 <br />Mike Huggins, R.E.H.S., R.D.I. <br />gg <br />Assistant Director Telephone: (209) 468-3420 <br />KaseyL. Foley, R.E.H.S. <br />MarargargaretLagono, R.E.H.S. <br />Fax: (209) 464-0138 <br />Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/ehd <br />Jeff Carruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATIO—N� � � � � t <br />1. Site Name: Det, c,gky 'rgtww V641 V.t r� <br />Address: I -Z" f es, Ann <br />Contact Person: MXV Phone No: 92,14 -46 ( Z <br />Sweeps Number: <br />Proposed Date of investigation/inspection: 610 11-L <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation- <br />❑ UAR Investigation. <br />❑ Tank Closure in Place.. <br />❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. <br />❑ Re -excavation. <br />❑ Installation of Borings / Monitoring <br />Wells. <br />Hazardous waste inspection <br />❑ Sampling <br />Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: Tank <br />Tank Content Tank <br />4. Type of Operation: a ��✓`� <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any prcvious investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Heat or Cold Stress: OF (high ambiem temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, nips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />In Corrosive <br />IN Dusts:_ <br />Explosive <br />® Flam nabl <br />❑ Inorganic <br />❑ Metals:_ <br />❑ Oxidizers <br />❑ PCB's:_ <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instrwnents are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />"i; <br />❑ Confined space entry: (explosions): ® Safety vest. <br />❑ Heavy equipment (physical injury & trauma resulting from moving ❑ Two-way communication. <br />equipment): <br />❑ Other, <br />7. Anticipated Biological Hazards: <br />Snakes KInsects �1Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.) <br />EH 23081 (02/19/03) <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: M Naidu Date: 41111(7, <br />(/Y� <br />Plan Approved by: V 1 Date: <br />