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ry� f ao.RA�;HQ.coy< <br /> ENVIRAIENTAL HEALTH AARTMENT <br /> Donna K. <br /> SAN JOAQUIN COUNTY <br /> • �+cikaa�v~• Program Coordinators <br /> Director <br /> r 600 East Main Street, Stockton, California 95202 Raley L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Robert McClellon,RE.H.S. <br /> Web:www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH & SAFETY PLAN <br /> PART I PART II <br /> GENERAL Sl%FORRM,r}TI,(�1N. EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name:_ '�V�(VX 1.1. Chemicals Hazards <br /> Address: � �bl..�f { <br /> ,ffCaroinogens: <br /> Contact Person: SW dSiyvY, Phone p: <br /> .H'Cortosives: <br /> Proposed Date of investigation/inspection: ❑Dusts: <br /> ❑Explosives: <br /> 2. Description and brief narrative of inspection activity: ❑Flammables: <br /> ❑New UST installation ❑UAR Investigation ❑Inorganic Gases: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Metals: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑Oxidizers: <br /> ❑Installation of Borings/Monitoring Wells ❑PCBs: <br /> , Hazardous waste inspection ❑ Sampling <br /> ❑Tiered Permitting inspection PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: L Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other. <br /> ❑Detector Tubes(specify): <br /> ❑Photo ionization Detector <br /> 4. Type of Operation/ r r t t ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: ❑None(see below) <br /> Evidence of leaks/soil contamination: ❑YES 'ONO 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 ®D <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®}lard Hat <br /> e Heat or Cold Stress: OF(high ambient temp.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek <br /> etc.): <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): <br /> AT cartridge: <br /> eary equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): <br /> ❑Other(specify): ❑Two-way communication <br /> ❑ <br /> Other(specify): <br /> 7. Anticipated Biological Hazard <br /> Snakes Insects ❑Rodents ❑Poisonous Plants PART IV-P <br /> s: <br /> ❑ APR VAL <br /> ❑Other/U .(specify): <br /> Plan Prepared by: Date: V U <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) Plan Approved by: I� Date: <br /> EH 23081(3/92010) <br /> 1 <br />