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sap4t�!N,. <br /> lCOJ <br /> a , ENVIRONMENTAL HEALTH DEPARTMENT <br /> •C{��FOR�`P•• SAN JOAQUIN COUNTY program Coordinators <br /> Donna K Heran,R.E.H.S. Kase L.FoleyR.E.H.S. <br /> Director 1868 E. Hazelton Ave., Stockton, Califomia 95205 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/ebd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART] PART II <br /> GENERAL SITE iPORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards ,1_ �r <br /> Address: ❑Carcinogens, I W&' vl �/ 61 <br /> Contact Person: ❑Corrosives AOI fa,� <br /> Phone q: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> ❑Flammables: A6 <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: 6)1 <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> E]Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> pp ryazardous Waste inspection E]Tiered Permitting inspection <br /> (`� 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation:�Q, ` ,tl� A�,.�— ❑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&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C SO <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> El Excavation falls,tris slipping,cave-ins ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. <br /> ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): [I Respirator: ❑APR E]SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL - <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: DateOCtW I'v <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ) <br /> Plan Approved by:�`y Date: d <br /> EH 23081 (7/13/2012) <br />