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PqU{p <br /> z ENVIRON 74ENTAL HEALTH D ARTMENT <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY 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 /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: 1. Chemicals Hazards ` <br /> Address: '16Carcinogens: <br /> Contact Pers C ❑Corrosives: <br /> Phone#: up!� Z ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> ❑Flaromables: <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: 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 /> C� <br /> C]Detector Tubes(specify): <br /> 4. Type of Operation: W �( f ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NOone(see below) <br /> Documented Groundwater contamination: C]YES ❑NO If <br /> moniNtoring 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 ®D <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 /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls <br /> 'Handling and Transfer of a Hazardous Substance(fire,explosions,etc.) ®Hearing protection <br /> J� ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> -Q[Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> Equipment): Safety vest <br /> ❑Other.(specify): o-way communicationph <br /> ► l <br /> ❑Other(specify): <br /> 7. Anticipatedrotopical Hazards: <br /> ElSnakes sects C3 Rodents C3 Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared b Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): C n <br /> Plan Approved by: Date: <br /> EH 23081(3/5/2012) <br />