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.z ENVIRON ENTAL HEALTH Dt'ARTMENT <br /> N <br /> SAN JOAQUIN COUNTY <br /> Donna K.Heran,R.E.H.S. Program Coordinators <br /> Director 600 East Main Street, Stockton,California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Farr:(209)468-3433 Robert McClellon,R.E.H.S. <br /> JeffCatrueseo,R.E.H.S. <br /> Web:www.sigov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> FART I PART II <br /> GENERAL SITENFORMATI N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards J <br /> Address: c� S"�-1 {'r' )(Carcinogens: C r <br /> Contact Person: )? L9-4W ❑Corrosives; <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: '� 2� El Explosives: <br /> �]Flammables: (,Q <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: 1 <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair >J Oxidizers: <br /> ❑Tank/Pipe Removal ❑ Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installationOther: �} � <br /> ¢azardous Waste inspection C]Tiered Permitting inspection III""" <br /> �� PART III <br /> 3. Specific Site Information: 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 /> f � E] Detector Tubes(specify): <br /> 4. Type of Operation: ` ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks 1 sail contamination: C]YES ❑ NONone(see below) <br /> Documented Groundwater contamination: E] YES F-1NOif m itormg 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.) <br /> ❑Hard Hat <br /> Oise Sources: ❑Safety Glasses/Goggles <br /> El Oxygen Deficiency: Stee!toed shank shoes or boots <br /> xcavationtri s,falls ,slipping,cave-ins): El Flame retardant coveralls <br /> ( p <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 /> ' Meavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ❑Safety vest <br /> ❑Other(specify): 12�wo-way communication 157 uL _ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snake:'*sects ❑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 (neo Date; <br /> e.g.,power lines,integrity of dikes,terrain,etc.): TL <br /> Plan Approved by: V Date:Z� <br /> EH 23081(12/16/2011) <br />