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ENVIRO"ENTAL HEALTH DkPARTMENT <br /> Donna K.Haran,R.E.H.S. SAN JOAQUIN COUNTYProgram Coordinators <br /> Director 600 East Main Street, Stockton,California 95202 Kasey L. Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carrucsrso,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE FORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: ✓1 l 1. Chemicals Hazards <br /> Address: ¢.�0� QYl <br /> / /1�Carcinogens: <br /> Contact Person: Phone#: �IrlY� <br /> ❑Corrosives: <br /> Proposed Date of investigatioNmapection: O <br /> ❑Dusts: <br /> [J Explosives: <br /> 2. Description and brief narrative of inspection activity: ❑Flammables. <br /> ❑New UST installation ❑UAR Investigation <br /> E]Tank Closure in Place C]Inorganic Gases: <br /> ❑TanWPipe Repair <br /> ❑Tank/Pi a Removal ❑Metals: <br /> Tank/Pipe ❑Re-excavation <br /> ❑Oxidizes: <br /> ❑Installation of Borings/Monitoring Wells ❑PCBS: <br /> azardous waste inspection ❑ Sampling <br /> LJ Tiered Permitting inspection PART III <br /> 3. Specific Site Information: <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.:-Tank Capacity:_ I. Monitoring Equipment(Note:Monitoring instruments must be used for all Tame Content Tank Age: operations unless appropriate ppropriate rationale or restrictions are provided): <br /> pC]Combustible Gas/Oxygen Meter <br /> Other: <br /> c y s ❑Detector Tubes(specify): <br /> MOW M� ❑PhotOrganic <br /> ionization Detector <br /> 4. Type of Operation: <br /> ❑Organic Vapor Analyzer <br /> ,,,��❑,�////���O����'ther(specify): <br /> 5. Release History: one(see below) <br /> Evidence of leaks/soil contamination: ❑YES O�No If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: El YES NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C E D <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) E Hard Hat <br /> ❑Heat or Cold Stress: °F(high ambient temp.) E Safety Glasses/Goggles <br /> ❑Noise Sources: E Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation:(falls,nips,slipping,cave-ins): E Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek <br /> etc.): <br /> ❑Respirator. [I APR ❑SCBA <br /> ❑Confined space entry(explosions): <br /> A/P cartridge: <br /> navy equipment(physical injury&trauma resulting from moving <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-PLAN APPROVAL <br /> ❑Othernknown(specify): (y l <br /> Plan Prepared by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, � <br /> e.g.,power lines,integrity of dikes,terrain,etc.) Plan Approved by: U Dale: I <br /> EH 23081(3/92010) <br />