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< <br /> EwmoNMENTAL HEALTH D!PARTMENT <br /> SAN JOAQUIN COUNTYprogram Coordinators <br /> Donna K.Heran,R.E.H.S. <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 /> Jeff Crrruesco,R.E.H.S. <br /> Web:www.sjgov.org/chd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:�l" /A�J,��y1IA 1. Chemicals Hazards <br /> AddressFJ Carcinogens: <br /> Contact Peson: r-" If� �P. ,(a'C0nwives: 4'*C /.�ndjv0 <br /> Phone#: R7LO-I r< 10 ❑Dusts: <br /> Proposed Date of investigation/inspection: 19 e1.IS , I ❑Explosives: <br /> Flammables: .JIM <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation „['Metals:iZ0,IW. S�M /vtlS <br /> ❑Tank Closure in Place ❑TamkJ?ipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Ro-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑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 rmlen appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meta <br /> J ��" 1�",, ❑Detector Tubes(specify): <br /> 4. Type of Operation: {'\iJ lr,i.�-4A f 1 D G7,(J )S f5 W i0 ❑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: IF(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cavo-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑HeavY equipment(phsical injury y&trauma resulting from mov. <br /> A/P Cartridge: <br /> equipment): mg <br /> ®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: Data: (,S <br /> e.g.,power fines,integrity of dikes,terrain,etc.): U <br /> Plan Approved by: QV Date: <br /> EH 23081(5/9/2011) <br />