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� � <br /> y <br /> Q: ENVIROA, ENTAL HEALTH AARTMENT <br /> w: <br /> " ... _ SAN JOAQUIN COUNTY program Coordinators <br /> 9e'FO"a Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Robert McClellon,R.E.H.S. <br /> Telephone: (209)468-3420 Fax.(209)468-3433 Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: Q� 1. Chemicals Hazards -V / <br /> Address.. .3 _ ���� Carcinogens: _ <br /> Contact Person: <br /> ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of hrvestigation/inspection: FJ CP ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-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: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Age:— operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: g ' ❑Combustible Gas/Oxygen Meter <br /> Other: <br /> n '4�� [I Detector <br /> Detector Tubes(specify): <br /> /r Photo ionization Detector <br /> 4. Type of Operation: r �— ❑Organic Vapor Analyzer <br /> Other(specify): <br /> 5. Release History: None(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES El NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A El B El C ®D <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Het <br /> ❑��sHeat or Cold Stress: °F(high ambient temp.) ®Safety Glasses/Goggles <br /> IPNoise Sources: <br /> ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> xcavation(falls,trips,slipping,cave-ins): ®Hearing protection <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Tyvek <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> 9eeavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> uipment): <br /> ❑Other(specify): 10Two-way communication OrLR­ <br /> ❑Other(specify): <br /> 7. .paced Bi logical Hazar�d�.,s:� <br /> n[ . rakes [Insects LyrRodents ❑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.. <br /> Daze: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: 0 <br /> EH 23081(4/72010) <br />