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O PQUt/y, <br /> EN'VIROI-iMENTAL HEALT EPARTMENT <br /> 2; .G <br /> --- SAN JOAQUIN COUNTY <br /> Donna K.Heran,R.E.H.S. 304 East Weber Avenue,Third Floor Program Coordinators <br /> Carl Borgman,R.E.H.S. <br /> Director Mike Huggins,R.E.H.S. <br /> Stockton, California 95202 gg' ,R.D.I. <br /> Laurie A.Cotulla,R.E.H.S. <br /> Assistant Director Telephone: (209) 468-3420 Kasey L.Foley,R.E.H.S. <br /> Margaret Lagorio,R.E.H.S. <br /> Fax: (209)464-0138 Robert McClellon,R.E.H.S. <br /> Web: www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SITE HEALTH&SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION r� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: r1. — / L 1. Chemicals Hazards <br /> Address: /SZn R J e4 Carcinogens: <br /> Contact Person:—M[Ai,ivPhone No: �l 7� �Corrosives: <br /> Sweeps Number: �J Dusts: w <br /> Proposed Date of investigation/iispection:_ !y'231 12- Explosives: <br /> ]Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ❑Hazardous waste inspection ❑ Sampling <br /> ❑Tiered Permitting inspection 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 /> ,�v jam, <br /> El Detector Tubes(Specify). <br /> 4. Type of Operation: It Y!�� 7'� /" ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: El YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> E]Excavation: Tyvek.Excavation:(falls,trips,slipping,cave-ins): , <br /> ❑ APR❑ ❑SCBA <br /> Handling and Transfer of a Hazardous Substance:(fire,explosions, Respirator: <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify: PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by: M Naidu Date: -2 312- <br /> 0 Snakes M Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): l <br /> Plan Approved by: V Date: b <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />