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Pgy1N <br /> so.�e.co <br /> ENVIROOMENTAL HEALTH APARTMENT <br /> SAN JOAQUIN COUNTY <br /> Program Coordinators <br /> Donna K.H rectorran,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 /> Web: www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFOWTION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: 1. Chemicals Hazards <br /> Address: *(,g0 <arcmogens: <br /> Contact Pers//o��n:��U 7Z /1' ❑Corrosives: <br /> Phone; CGo9 ���� ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> OFlammables: <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 /> � <br /> ampling [I Boring/Monitoring Well installation El other: <br /> azardous 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 /> � � <br /> El Detector Tubes(specify): <br /> 4. Type of Operation: El Photo ionization Detector <br /> Organic Vapor <br /> Elrg aP 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 ND <br /> ❑Heat or Cold Stress: of(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 A/P Cartridge: <br /> -equipment): ®Safety vest <br /> ❑Other(specify): Two-way communicatior)Wharze— <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> %,y:nakes Insects VRodents ❑Poisonous Plants PART IV <br /> u 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 (4/7/2010) <br />