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SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: P14HLJF <br />Address: 7 ?SD P. A- Rr 101 1e Ar A <br />Contact Person: Vi.a�Phone No: ✓ <br />Sweeps Number. <br />Proposed Date of investigationlinspection: & I 11 I I �- <br />2. Description and brief narrative of inspection activity: <br />ENVIROENTAL <br />HEALTAEPARTMENT <br />❑ Tank Closure in Place.. <br />❑ Tauk/Pipe Repair. <br />❑ Taak/Pipe Removal. <br />❑ Re -excavation. <br />qpW <br />Wells. <br />SAN JOAQUIN COUNTY <br />❑ Sampling <br />® Tiered Permitting inspection <br />Donna x. Reran, R. E.H.S. <br />304 East Weber Avenue Third Floor <br />. <br />Prograar Coordinators <br />Carl Bergman, R.E.H.S. <br />Director <br />Laurie A. Cotulla, R.E.H.S. <br />Stockton, California 95202 <br />Mike Huggins, R.E.H.S., R.D.I. <br />Assistant Director <br />Telephone: (209) 468-3420 <br />Kasey L. Foley, R.E.H.S. <br />Fax: (209) 464-0138 <br />Margaret Lagorio, R.E.H.S. <br />Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/ehd <br />Jeff Carruesco, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: P14HLJF <br />Address: 7 ?SD P. A- Rr 101 1e Ar A <br />Contact Person: Vi.a�Phone No: ✓ <br />Sweeps Number. <br />Proposed Date of investigationlinspection: & I 11 I I �- <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation.. <br />❑ UAR Investigation. <br />❑ Tank Closure in Place.. <br />❑ Tauk/Pipe Repair. <br />❑ Taak/Pipe Removal. <br />❑ Re -excavation. <br />❑ Installation of Borings / Monitoring <br />Wells. <br />® Hazardous waste inspection <br />❑ Sampling <br />® Tiered Permitting inspection <br />3. Specific Site bribnnation: <br />Tank <br />Tank <br />Tank <br />PART H <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />ki corrosive <br />Dusts:_ <br />(�1 Explosive <br />[� Flammab <br />❑ Inorganic <br />❑ Metals:_ <br />❑ Oxidizers <br />❑ PCB's:_ <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />4. Type of Operation: ELVMJt L4 qa-Z#,rG� ap C. AA. i-w[� <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwatorcontamhnation: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Heat or Cold Stress: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Tranger of a Hazardous Substance: (fine, explosions, <br />❑ Confined space cat y: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />❑ Other, <br />Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: [I A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />fR <br />,` aTwo-way communication. <br />PART IV - PLAN APPROVAL <br />7. Anticipated Biological Hazards: Plan Prepared by: M Naidu Date:V I Z <br />El Snakes '� Insects 1,;A Rodents E] Poisonous Plants <br />❑ Other/Unknown (specify): �( <br />Plan Approved by: J Date: <br />8. Narrative (provide all information which could impact Health and Safely, <br />e.g., power lines, integrity of dikes, terrain, etc.) <br />EH 23081 (02/19/03) <br />