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'OPytu lly <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • d;iacca''�P• SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.DirectHeranor <br /> R.E.H.S. Kase L.Foley,Director 600 East Main Street, Stockton, California 95202 Y y,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> J <br /> Web: www.sjgov.org/ehd effCarruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION �-. �L EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: r 1, llA.[l l 1. Chemicals Hazards <br /> Address: ftc3 /,tVl.� 'LU <br /> . � n �Carcinogen <br /> s: PMi&0- V <br /> Contact Person- ❑Corrosives: <br /> Phone q: g-- ax;L I <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> x]Flammables: �/ <br /> 2. Description and brief narrative of inspection activity: T Inorganic Gases X4' QM O, �� <br /> EI New UST installation C3UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> rs�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 most be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> rr��,,,,,,,,1l,,,, �L <br /> C3 Detector Tubes(specify): <br /> 4. Typeof0pemtion: �Vmv & Col.{�lho fes_ ❑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 LINO 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: OF(high ambient temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ® <br /> Oxygen Deficiency: Steel toed/shank shoes or boots <br /> ❑ <br /> ❑ <br /> ❑Excavation(falls,trips,slipping,cave-ins): Flame retardant coveralls <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> ❑ <br /> ❑Confined space entry(explosions): Respirator: [I APR C]SCBA <br /> ❑Heavy equipmenm <br /> t(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): Two-way communication CdL 1 <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑ 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.): <br /> 0 <br /> Plan Approved by: <br /> Date: g 13 t <br /> EH 23081(8/6/2010) <br />