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pqu rp <br /> yo. ,co <br /> e. <br /> ENVIRONI ENTAL HEALTH DEPARTMENT <br /> fi ..... .: . SAN JOAQUIN COUNTY <br /> t� One Donna K.Heran,R.E.H.S. Program 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 /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards r <br /> Address: carcinogens: <br /> Contact Person: orrosives: <br /> Phone#: Dusts: <br /> Proposed Date of investigationlinspection: ❑Explosives: qq�, ,,, /� <br /> �7ammabim CK�i fi'W -1_IW <br /> CJ <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 Wxidizers:f(U1J04(, 1 <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 Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> [IDetector Tubes(specify): <br /> 4. Type of Operation:-r L AIVC41�� ❑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 ZD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) 0 Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: 0 Steel toed/shank shoes or boots <br /> xcavation(falls,trips,slipping,cave-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 /> 19�c! equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®safety vest <br /> ❑Other(specify): �Owo-way communication Pr t V'u-1 <br /> ❑Other(specify): <br /> 7. Anticipated Biological H <br /> akes >rLects Rodents ❑Poisonous Plants PARTIV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ]� <br /> Q�' <br /> Plan Approved by: tj S Date: <br /> EH 23081(515/2011) <br />