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7CV'4� <br /> �ENVIROA,1ENTAL HEALTH D ARTMENT <br /> SAN JOAQUIN COUNTY• 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 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 EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site N 1. Chemicals Hazards,q., )� <br /> Address: - XCarcinogens: C/r/s an-619 ze ze <br /> i <br /> Contact Person: ❑Corrosives: <br /> Phone#: — 2 ❑Dusts: <br /> Proposed Date of investigation/inspection: '-2rJ ❑Explosives: <br /> XFlammables: Sa 1y41-V). S <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Owes::� '� <br /> ❑New UST installation ElUAR Investigation �&etals�&X.6i <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: 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 /> ' //n ❑Detector Tubes(specify): <br /> 4. Type of Operation: L�/.l'[(l K2�f �Q ja2i " ❑Photo ionization Detector <br /> —T — ❑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 /> *'Oise Sources: ®Safety Glasses/Goggles <br /> �E]/Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> j_I+`.Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> Handling and Transfer ofa 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 AT Cartridge: <br /> equipment): ®Safety vest a� <br /> Other(specify): �<wo-way communication PhoKw- - <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> CAnakes 'JqQnsects *IKkodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan prepared by. Date: 5 6 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: �� Dale: b l <br /> EH 23081(2/7/2011) <br />