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Pg4ik <br /> ENVIRONMENTAL HEALTH D PARTMENT <br /> e4�iFpA:i-� <br /> Donna K.Henan,R.E.H.S. SAN JOAQUIN COUNTY 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 Name: I. Chemicals Hazards <br /> Address: /3 7 X. sfDC cy- carcinogens: <br /> Contact Person: ❑Corrosives: <br /> Phone#: A-7 —0,70 [3 Dusts: <br /> Proposed Date of investigation/inspection: .� !/ C1 Explosives: <br /> Flammables: l�! f Q <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 Wxidizers:-nCA#4'L <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> C1 Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> KAazardous 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 /> Othen ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: azz"3k I „ ai-i4 ❑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 OD <br /> ❑Heat or Cold Stress: °F(high ambient temp.) <br /> ®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 /> landiing and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®Hearing protection <br /> Na <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> Heavy equipment(physical injury&tmu a resulting from moving A/P Cartridge: <br /> equipment): Safety vest <br /> ❑Other(specify): 19two-way communication Ph O f'LQ_,, <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes "X' ]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 by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Ll <br /> Plan Approved by: Date: <br /> EH 23081(2/7/2011) <br />