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aq'RA�a Foy <br /> "< ENVIRONMENTAL HEALTH APARTMENT <br /> ••e'fC!'saYidJ• <br /> Donna K.Henan,R.E.H.S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,RE.H.S. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Robert McClellon,RE.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 /> GENERALS 1]V� TION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Nam e• �� � �, 1. Chemicals Hazards <br /> Address:1/A�r N//�it//� _ 'Carcinogens:�bSUY YXAI/S <br /> Contact Pets �11 ❑Corrosives: <br /> Phone#:,_ ❑Dusts: <br /> Proposed Date of investigation/mispection: L ? <br /> / J ❑Explosives: <br /> i )W Flammables: 2J�1Ld7.D1 r�IP�P <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 /> [I Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> alp Hazardous Waste inspection El Tiered Permitting inspection <br /> \o <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 /> I—' .L <br /> C]Detector Tubes(specify): <br /> 4. Type of operation, rUL( 1(��rC?e26 LU12bh ❑Photo ionization Detector <br /> Ci ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(spei:nh'): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO �0 None(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 ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toe&shank shoes or boots <br /> xcavationfalls,tri ❑Flame retardant coveralls <br /> ( trips,slipping,cave-ins): <br /> andling and Transfer of a Hazardous Substance(fire,explosions,etc.): ®Hearing Protection <br /> [I Tyvek <br /> ❑ <br /> C]Confined space entry(explosions): Respirator. [I APR [I SCBA <br /> )9r�r`'.esvy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> I equipment): ®Safety vest �^ <br /> Other(specify♦7•� Two-way,communication Y„072e--�' <br /> 1911 nher(specify):T <br /> 7. Anticipated Biological Hazards: 7` <br /> P$nakes �P*ects'�<Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared 4 1 Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): f <br /> I <br /> Plan Approved by: L Dale.-61 I ` ` <br /> EH 23081(3/5/2012) <br />