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ENVIRONMENTAL HEALTH AARTMENT <br /> , �4t/FORp��• <br /> Donna K Heran,R.E.H.S. SAN JOAQUIN COUNTY 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 Canuesco,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 IR <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: 1. Chemicals Hazards /. <br /> Address: /l r�'1�. �Caroinogens: w e u <br /> Contact Person: 9CYorrosives 1 <br /> Phone#: q ��� —O ❑Dusts: �/'. !/a !L <br /> Proposed Date of investigation/inspection: — Explosives: Fes' <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: DA14 <br /> ❑Tank/Pipe Removal ❑Re cxcavation ❑PCBs: 00 <br /> ❑Sampling ❑Boring/Monitoring Well installation Other:0 <br /> az <br /> /� .Y1F7tP1' <br /> ;{azardous Waste inspection ❑Tiered Penn fitting inspection .p y +, f[�'y1.11'Lp I a,AL(.CIYi <br /> II ' <br /> PART I <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 /> ��f��}�-���, ��,��n JJJ,,,,,,,,,,,, ��' ❑Detector Tubes(specify): <br /> 4. Type of Operation: r .2p�%�Q ❑Photo ionization Detector <br /> J I ❑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 we 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 ED <br /> ❑Heat or Cold Stress: OF(high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> dcavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.); ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Meavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> 111�e�,,rmipment): E Safety vest {��`- <br /> �ytr�ther(spm_ecify): �'wo-way communication) jlzo V <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> �*nakes Insects XRodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan prepared ate: Id <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: q'14•lL <br /> EH 23081(3/5/2012) <br />