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�C�G <br /> ENVIRONIRENTAL HEALTH DL+ ARTMENT <br /> �YrFcaa+".� SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.HeranDirector <br /> RE.H.S. Kase L.Fol R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 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,RE.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION /`-/� I c EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name -P�4gi -, l�/_Y-a oo— 4, 5+ I. Chemicals Hazards <br /> Address: L4114 at 16 !�s1,!-+. �J.�,., ❑Carcinogens: <br /> 1 T <br /> Contact Perso I'v).c-- , ❑Corrosives: <br /> Phone#: 'Z`ti ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑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: L 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 /> /� /' /'� / ❑Detector Tubes(specify); <br /> 4. Type of Operation: /" /+-�I'o /(.c,0 1r- / !? S`a/'V�— ❑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 ®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 /> ❑ <br /> C]Excavation(falls,trips,slipping,cave-ins): Flame retardant coveralls <br /> -i$Hundling and Transfer of a Hazardous Substance(fine,explosions,etc.):, <br /> ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving 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 <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 /> Plan Approved by: �� Date: <br /> EH 23081(12/9/2011) <br />