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�Q4r�UIN.. <br /> t:' . .coy •• <br /> a ENVIRONIGIENTAL HEALTH APARTMENT <br /> Donna K. SAN JOAQUIN COUNTY Program Coordinators <br /> Director R.E.H.S. 600 East Main Street, Stockton,California 95202 Kasey L.Foley,RE.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Robert McClellon,RE.H.S. <br /> Jeff Carruesco,RE.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,RE.H.S. <br /> SUE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION /' EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: S.-r�P I P�•rinC/a ltw %i�I9iY ') 1. Chemicals Hazards <br /> Address: oP IV r E]Carcinogens: <br /> Contact Person: Yf ❑Corrosives: <br /> Phone#: X03 ❑ousts: <br /> Proposed Date of investigation/inspectiow '3 2 I (I Explosives: <br /> )2rFlamarables: 22&1 dYli1 Sl <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 ❑Oxidizes: <br /> ❑Tank/Pipe Removal ❑Recxcavation ❑PCBs: <br /> ❑Sampling onng/Monitoring Well installation ❑Other. <br /> %Hazardous Waste inspection ,Tiered Permitting inspection <br /> PARTIII <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments most be used for all <br /> Tank Conten: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> r7✓�r rte- <br /> C]Detector Tubes(specify): <br /> 4. Type of Operation: 4- �r/hr�I_ ` ❑Photo ionization Detector <br /> ❑Organic Vapor Analyze' <br /> 5. Release History: ...���❑,,,,O[[['''ther(specify): <br /> Evidence of leaks/soil contamination: C]YES C1 NO one(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area rmt ictions: <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 Cl 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 /> 'Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> >'Hmrdling and Transfer of a Hazardous Substance(fire,explosions,etc.):. E Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> �❑Heavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): Two-way communication Py-0-Q- ' <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> Snakes <Iasects �R'odens ❑Poisonous Plants PART IV <br /> ❑ <br /> Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by Date.- <br /> e.g., <br /> ate:e.g.,power lines,integrity of dikes,terrain,etc.): Q7 <br /> Plan Approved by: Datet.) 2` <br /> EH 23081(2/72011) <br />