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op4u�~ c <br /> y: ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY Program Coortlinators <br /> ��FOR Donna K.Heran,R.E.H.S. <br /> 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Director Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Teff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:a? !�AI'n /CAiYI)J&b1Cxe ) ( ,1. Chemicals Hazards <br /> Address:, D l,C). L/rir F i2d Carcinogens: <br /> Contact Person: Corrosives: rA <br /> Phone#: 14 3 `p_Dusts:� l <br /> Proposed Date of investigation/inspection: c Explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: Inorganic Gases:, <br /> ❑New UST installation ❑UAR Investigation Metals: <br /> ❑Tank Closure in Place El Tank/Pipe Repair Oxidizers: �Xu <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> �eIazardous 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 /> 1 ❑Detector Tubes(specify): <br /> 4. Type of Operation:� ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: Gi ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO % one(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If mo/-going 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 ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) <br /> ®Hard Hat <br /> oise Sources: � '1 -'D'► d ®Safety Glasses/Goggles <br /> Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> xcavation(falls,trips,slipping,cave-ins): ElFlame retardant coveralls <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ®Hearing protection <br /> JJ�� ❑Tyvek <br /> ❑Respirator: ❑APR ❑ SC13A <br /> ❑Confined space entry(explosions): <br /> A/P Cartridge: <br /> �I-Ieavy equipment(physical injury&trauma resulting from moving <br /> ®Safety vest <br /> equipment): <br /> ❑Other(specify): [\Two-way communication 1-r <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes [ 61sects }Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepare by: Date: 5 �� <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: \� Date: 5 <br /> EH 23081(4/7/2010) <br />