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uIN � <br /> R4.... <br /> r <br /> ENVIROIV MENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna K Heron,RE.H.S. Program Coordinators <br /> Director 600 East Main Street, Stockton, Califomia 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Robert McClellon,R.E.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH At SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: J �7 1. Chemicals Hazards <br /> Address: d F p C'(r/I Ol O Carcinogens: <br /> Contact Person: C4joqf' ❑Corrosives: <br /> Phone k: 4 W)2 2 — ❑Dusts: <br /> Proposed Date of investigation/inspection: 9 /S O ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: Inorganic Gases:AMII 41U4 <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Twk/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> `0❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Yl dlazmdous Waste inspection El Tiered Permitting inspection <br /> ///��� PART III <br /> 3. Specific Site brfonnation: 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 /> � � "� �. � ❑Detector Tubes(specify): <br /> 4. Type of Operation: },/�� (� �/!/�[/7/(7J] ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: F-1�aaO'''ther(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO Vone(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 Concems:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> 11❑��,,��H,,''eat or Cold Stress: °F(high ambient temp.) Z Hard Hat <br /> oise Sources: ®Safety Glasses/Goggles <br /> Oxygen Deficiency: ®Steel toed/shmk shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. Z Hearing protection <br /> ❑Tyvek <br /> Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(phys cal injuq'&trauma resulting from moving A/P Cartridge: <br /> equipment): � 7n')A ®Safety vest <br /> ❑Other(specify): Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated ological Hazards: <br /> 'NfSnakes Insects k 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 b . Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: L Date (9 <br /> EH 23081 (4/72010) <br />