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ENVIRO•ENTAL HEALTH D 'PARTMENT <br /> ;... . ..:P SAN JOAQUIN COUNTY Program Coordinators <br /> ctPpiN Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 1868 E. Hazelton Ave., Stockton,California 95205 Robert McClellon,R.E.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Jeff Carruesco,R.E.H.S. <br /> Web: www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> Rodney Estrada,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN Adrienne Ellsaesser,R.E.H.S. <br /> PART I PART 11 <br /> GENERAL SITE INFORMATION, EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: UIOai l/ 1. Chemicals Hazards j1 <br /> Address:_ /gyp(Carcinogens: <br /> Contact Person: LJ Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: /r <br /> Flammables: 84".00 X_r <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 /> �>61azardous Waste inspection ❑Tiered Permitting inspection <br /> ❑Hazardous Materials Business Plan PART III <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> 3. Specific Site Information: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): <br /> Tank Content; Tank Age: ❑Combustible Gas/Oxygen Meter <br /> Other: ❑Detector Tubes(specify): <br /> �/— / <br /> El Photo ionization Detector <br /> 4. Type of Operation: Ga"t rSC, rl ❑Organic Vapor Analyzer <br /> ❑Other(specify): <br /> 5. Release History: `Q 61one(see below) <br /> Evidence of leaks/soil contamination: ❑YES ❑NO 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 VD <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& ❑Hard Hat <br /> 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 /> ❑Excavation(falls,trips,slipping,cave-ins): ❑Tyvek <br /> `� andling and Transfer of a Hazardous Substance(fire,explosions,etc.):. ❑Respirator: El APR ElSCBA <br /> ''\` A/P Cartridge: <br /> ❑Confined space entry(explosions): ❑Safety vest <br /> Heavy equipment(physical injury&trauma resulting from moving E]Two-waycommunication <br /> equipment): ❑Other(specify): <br /> [I Other(specify): <br /> PART IV <br /> 7. Anticipated Biological Hazards: PLAN APPROVAL <br /> El Snakes L7rinsects E]Rodents E]Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> EH 23081(12/2013) <br />