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'aRquty <br /> t. �a.coa <br /> a ENVIROOMENTAL HEALTH &PARTMENT <br /> ,.�4tikS1lt'p'• <br /> Donna K.Heran,RSAN JOAQUIN COUNTYE.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 <br /> STYE HEALTH& SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: MUSE-0 �/10 Ve CO. 1. Chemicals Hazards <br /> Address: 1717sb 60 , a /Y0/0 / 77IR941 Carcinogens: <br /> Contact Persa�:/.QAC' I2 IQlJL/� HR-P.O '{Corrosives: f�l <br /> Phone k: 1L0�1)8 0 OD ❑Dusts: <br /> Proposed Date of investigation/inspeaiom dr4y-- ❑Explosives: <br /> XFlammables: ( 7�UWi1 Ej rtoo bt-2. <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 JS�Qxidizers: &WW42 <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Imazardous 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: OGy/ aagz1a ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: YOther(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO POlone(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 ND <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®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 /> �J laadling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> 'JXjeavy equipment(p ysical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): 7LCYD'ry1 p®r Safety vest <br /> K❑Other(specify): , Two-way communication Pkme__ <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes hClnsects ❑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 tz <br /> Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: \ Date: to <br /> EH 23081(4/72010) <br />