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P�U1N <br /> �0" .CQ <br /> ENVIRO#ENTAL HEALTH &PARTMENT <br /> • FT�S+a�P SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. <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 /> SITE HEALTH& SAFETY PLAN <br /> PART] PART II <br /> GENERAL SITE ORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Addres Carcinogens: <br /> Contact Person: / ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> �'J�tFlammables: <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 ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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 /> ^��7� ❑Detector Tubes(specify): <br /> 4. Type of Operation: C/f' El Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> S. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO [)6one(see below) <br /> Documented Groundwater contamination: E]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: °F(high ambient temp.) ®Hard Hat <br /> �❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Fl Flame retardant coveralls <br /> Excavation(falls,trips,slipping,cave-ins): <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> Confined space entry(explosions): ElRespirator: [IAPR ElSCBA <br /> ,[Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> Zquipment): y ®Safety vest <br /> ❑Other(specify): ZTwo-way communication t0ha7?,(_� <br /> ❑Other(specify): <br /> 7. Anticipated B'ological Hazards: <br /> Onakes Insects -Rodents El Poisonous Plants PART IV <br /> ther/Unknown(specify): PLAN APPROVAL <br /> LZ_ <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared �"" Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): ' <br /> Plan Approved by: Date: �•��-1b <br /> EH 23081 (4/7/2010) <br />