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PgUiN <br /> Q: <br /> ENVIRO ENTAL HEALTH AARTMENT <br /> a: . < <br /> SAN JOAQUIN COUNTY <br /> �rFO"a Donna K.Heran,R.E.H.S. SAN Coordinators <br /> Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:wwwsjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> ]. Site Name: ll <br /> _ 1. �emicals Hazards <br /> Address: Carcinogens: <br /> Contact Person: P/Y� �� ❑Corrosives: <br /> Phone#: - CJ ❑Dusts: <br /> Proposed Date of investigationfinspection: o — � ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: 24 <br /> organic Gases: <br /> ❑New UST installation [IUAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑ <br /> Tari Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> �Gzardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. 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 /> p ❑Detector Tubes(specify): <br /> 4. Type of Operation: Hili! 01.F'������ ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑ her(specify): <br /> Evidence of leaks/soil contamination:: ❑YES [INO one(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 OD <br /> ❑Heat or Cold Stress: OF(high ambient temp.) E Hard Hat <br /> XNoise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> [EExcavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): E Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: [I APR ❑SCBA <br /> %gHcavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): �E Safety vest L , <br /> E]Other(specify): wo-way communication �Lo12.JL <br /> ther(specify): <br /> 7. Anticipated Biological Hazards: <br /> ekes "Zmsects ,Rodents ❑Poisonous Plants PART W <br /> Other/Unknown(specify): PLAN APPROVAL D <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by. Date: G <br /> e.g.,power lines,integrity of dikes,terrain,etc.): , _I A <br /> Plan Approved by: {M� Date: �-_,�t 0 <br /> EH 23081(4/7/2010) <br />