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x ENVIROAkENTAL HEALTH DWARTMENT <br /> C, L1F�:a��r`• SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heron,R.E.H.S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 y y <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 {"4fit EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name;--LZ _11 [�—�� l�M�� __ � 1. Chemicals Hazards <br /> Address: J Carcinogens: <br /> Contact Person: PZ � (S�YLc _ Corrosives: <br /> Phone 3 Gly ❑Dusts: <br /> Proposed Date of investigation/inspection: l i?�1 112 10 ❑Explosives: <br /> '^Q Flanunables: <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 1 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 unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> r ❑Detector Tubes(specify): <br /> 4. Type of Operation: J 'AI�f IZ�L��L L'A s` [3 Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks!soil contamination: ❑YES ❑NO <br /> ❑None(see below) <br /> Documented Groundwater contamination: ❑YES El 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 ❑D <br /> ❑Heat or Cold Stress: °F(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,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 /> Heavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): 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 f <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: A4 r1Jr Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): y <br /> Plan Approved by: �✓r� Date � L <br /> EH 23081(1216/2010) <br />