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4pu I!Y. <br /> ENVIROOMENTAL HEALTIODEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> �` vc aur Donna K.Heran,R.E.H.S. 304 East Weber Avenue, Third Floor program Coordinators <br /> t.r a Director Carl Bergman,R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. Stockton, California 95202 Mike Huggins,R.E.H.S.,R.D.I. <br /> Assistant Director Telephone: (209) 468-3420 Kasey L.Foley,R.E.H.S. <br /> Margaret Lagorio,R.E.H.S. <br /> Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Web: www.sjgov.org/chd Jeff earruesco,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION / EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 4 Vu4 ✓wrtlfv/}a74 _�_ <br /> 1. Chemicals Hazards <br /> Address: 2a 131 1 L1_1,1_13 3 1N Carcinogens: <br /> Contact Person: Phone No: IN Corrosives: <br /> Sweeps Number: R]Dusts: <br /> Proposed Date of investigation/inspection: 41-1-7.117— Cel Explosives: <br /> (21 Fla amables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place.. ❑Taak/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> N Hazardous waste inspection ❑ Sampling <br /> ❑Tiered Permitting inspection PART IH - <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: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑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/soil contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: []YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C go <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> F-1NoiseSources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑ <br /> C1 Excavation:(falls,nips,slipping,cavo- Tyvek.ins): , <br /> ❑ <br /> Handling and Tmns(er of a Hazardous Substance:(foe,explosions, Respirator: El APR El SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> (Heavy equipment(physical injury&trauma resulting from moving (3 Two-way communication. <br /> equipment): <br /> ❑Other,specify: PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by: M Naidu Date: i 2 <br /> Snakes CKInsects 0 Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Ru Date: <br /> S. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (02/19/03) <br />