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i ENVIRONMENTAL HEALTH DEPARTMENT <br /> •�ggiFb ��°• <br /> Donna K.H R.E.H.S. SAN JOAQUIN COUNTY program Coordinators <br /> Director <br /> 1868 E.Hazelton Ave., Stockton,California 95205 Kasey L.Foley,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellan,R.E.H.S. <br /> s ov.or ehd <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www <br /> 1g F� Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SrORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: ❑Carcinogens:l�/KI4l 61� ar rout zth4, Qp�7�4"'-r�'Y <br /> Contact Person: El Corrosives, <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: I 1— 19 1 12 ❑Explosives: <br /> ❑Flammables' oy 41n <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑CAR 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 /> Ir <br /> Waste inspection El 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 /> QQ ❑Detector Tubes(specify): <br /> 4. Type of Operetion: f,r �� �i�(1,�,[J ❑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 ❑NO If monitoring instruments are not used,rationale or activity/area restrictions* <br /> Backgrota d and description of any previous investigation or incidence: <br /> Z Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C M D <br /> ❑Heat or Cold Stress: °F(high ambivert temp.) ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: <br /> ®Steel toed/shank shoes or boots <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 /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <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.): UZI <br /> Plan Approved by: V <br /> EH 23081(8/14/2012) <br />