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ENVIRCKI MENTAL HEALT"EPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Unit Supervisors <br /> Direrectorctor <br /> Donna K.H R.E.xs. 304 East Weber Avenue, Third Floor Carl Bergman,R.E.H.S. <br /> AI Olsen,ILE.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> Douglas W.Wilson,R.E.H.S. <br /> • cq:tFOR��P• Program Manager Telephone: (209)468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Cotulla,RE.H.S. Fax: (ZO9)464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: S7SD 1 &,A 1 SF AYV EfCarcinogens: <br /> Contact Person: XfA MF4QA WAWA Phone No: S-i's , Irrcorrosives: <br /> Sweeps Number: 9Dusts: <br /> Proposed Dale of investigation inspection: 4' 1 <br /> �❑Explosives: <br /> Lh lammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ErMetals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe M/Repair. f NLp, ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re�cx� ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> A ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: c%LwA PI.Rr�I' ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: <br /> ❑YES &NG El Other,specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: [I YES [,SMO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ❑D <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) R Hard Hat. <br /> rS <br /> Safety Glasses/goggles. <br /> Hear or Cold Stress:' °F(high ambient temp.) <br /> [Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> E]Respirator: E3 APR [ISCBA <br /> etc..): <br /> ❑Confined space may:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): [ Two-way communication. <br /> [Other,specify KA(tflOMf'!J <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: PK <br /> ,a.�1/� -.f�ryt <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: PKK 4 i fPh l"li rD LllO0 <br /> ate: <br /> [R�Other/Unknown(specify): LI�.�U�1 p / <br /> Plan Approved by: Date: a .66 <br /> 8. NNarrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />