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rsa4�;a...9os �� <br /> < EN"ROAENTAL HEALTH 1AARTMENT <br /> •` +rikoR: ' SAN JOAQUIN COUNTY Program Coordinators <br /> Director Doane K. R.E.H.S. 600 East Main Street, Stockton, California 95202 Kasey L. Foley,R.E.H.S.Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Cartuesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Ttukatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: 7— 1. Chemicals Hazards /� <br /> Address: 05 'OC.0-I'L , VCarcinogens:�, Ixpy1'(�WAA. J <br /> Contact Person: — L ❑Corrosives: <br /> Phone p: 2- ❑Dusts: <br /> Proposed Date f investigation inspection: ❑Explosives: <br /> VFlammables:FittQ.g-O �'f O_ <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: n( <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 /> n ^ _�n ❑Detector Tubes(specify): <br /> 4. Type of Operation: (.cam+ ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify); <br /> Evidence of leaks/soil contamination: ❑YES ❑NO tone(see below) <br /> Documented Groundwater contamination: ❑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 ZD <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 hoots <br /> cavation(falls,trips,slipping,cave-ins): El Flame retardant coveralls <br /> dandling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): OTwo-way communication P <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes Insects "�Oodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknowa(specify): PLAN APPROVAL <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: U Daze:Z 2� <br /> EH 23081 (12/162011) <br />