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r.� <br /> ENVD&NMENTAL HEALTH EPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna K.Aeraq RE.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 /> Web:Www.sjgov.orglehd Jeff Carruesco,R.E.H.S. <br /> Linda Turkatte,R.E.H.S. <br /> STYE HEALTH&SAFETY PLAN <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name 'ifi. C,�..(�e� Z c�.eI 1. Chemicals hazards <br /> Address: C.t 7L5 nJ t��,t� L.c.-e. Cl Carcinogens: <br /> Contact Person: <br /> Phone#: ❑Corrosives: <br /> C3 Dusts: <br /> Proposed Date of investigation/inspection: .1^7> ❑Explosives: <br /> 2. Description and brief narrative of ❑Plarganic s. <br /> inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation <br /> ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> 3. Specific Site Information: PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitorin <br /> Tank Content: g F-4wPment(Note:Monitoring instruments must be used for all <br /> Tank Age: operations MIME appropriate rationale or restrictions are provided): <br /> Othec: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: ❑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 /> Background and description of my 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.) ®Hard Hat <br /> ,13+ Noise Sources: 4_:,..e yy�.,i ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins); ❑Flame retardant coveralls <br /> -0 Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hear°g Protection <br /> v 1 ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving AT Cartridge: <br /> equipment): ®Safety vest <br /> 14 Other(specify): t. V4 /is ❑Two-way,communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards; <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑ <br /> Other/Unknown(specify): PLAN APPROVAL ) <br /> 8. Narrative(provide <br /> rovide all information which could impact Health and Safety, Plan Prepared by <br /> e.g., integrity of dikes,tenpin,etc.): Data. / <br /> Plan Approved by:_ RS (f U Date: ' <br /> EH23081 (12/6/2010) <br />