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�o,�• C' <br /> 2:• <br /> a ENTwR(WMENTAL HEALTH 10'PARTMENT <br /> c��IFORN�' SAN JOAQUIN COUNTY <br /> Donna K Heran,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.org/ehd Jeff Carruesco,R.E.H.S. <br /> Linda Turkatte,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN' <br /> PART-1 <br /> GENERAL SITE INFORMATION — <br /> EVALUATION OF POTENTIAL HAZARDS <br /> ]. Site NameCl L Chemicals Hazards <br /> Address: O <br /> Contact Pelson: o se—, � 4 s d <br /> ❑Carcinogens: <br /> Phone#1: <br /> �� ❑Corrosives: <br /> �'I S'Z �Z21?� <br /> ❑Dusts: <br /> Proposed Date of investigationAnspection:_ 4---7-9 ,i f <br /> ❑Explosives: <br /> 2. Description and brief narrative of in Flammables: <br /> spection activity: ❑Inorganic Gases: <br /> 0 New UST installation 0 UAR Investigation ❑Metals: <br /> 0 Tank Closure in Place ❑Tank/Pipe Repair <br /> ❑Oxidizers: <br /> 0 Tank/Pipe Removal ❑Re-excavation <br /> ❑PCBs: <br /> 0 Sampling ❑Boring/Monitoring Well installation <br /> ❑Dater: <br /> JK Hazardous Waste inspection 0 Tiered Permitting inspection <br /> 3. Specific Site Information: PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: <br /> Tank Content: l• Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> n 1 1] ❑Detector Tubes(specify): <br /> 4. Type of Operation: rCaM / Tag ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: 0 Other(specify): <br /> Evidence of leaks/soil contamination: 0 YES 0 NO 0 None(see below) <br /> Documented Groundwater contamination: 0 YES 0 NO If monitoring instruments are not used,rationale oractivity/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.) 0 Hard Hat <br /> ❑Noise Sources: 0 Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: 0 Steel toed/shank shoes or boots <br /> Q Excavation(falls,trips,slipping,cave-ins)- 0 Flame retardant coveralls <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): 0 Hag protection <br /> 0 Tyvek <br /> ®'Confined space entry(explosions): 0 Respirator: ❑APR 0 SCBA <br /> 0 Heavy equipment(physical injury&trauma resulting from moving AR'Cartridge: <br /> equipment): <br /> 0 Safety vest <br /> 0 Other(specify): <br /> ❑Two-way communication <br /> 7. Anticipated Biological Hazards: ❑Other(specify): <br /> 0 Snakes 0 Insects 0 Rodents ❑Poisonous Plants <br /> PART N <br /> 0 Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by <br /> e.g.,power lines,integrity of dikes,terrain,etc.): Q Date: 'S <br /> Plan Approved b 'PU 1 Date: I�' <br /> i <br /> EH 23081 (12/6/2010) i <br /> Ilj <br />