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Donna K. Heran, R.E.H.S. <br />Director <br />ENVIROI , 1ENTAL HEALTH DWARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />Web: www.sjgov.org/ehd <br />Program Coordinators <br />Kasey L. Foley, R.E.H.S. <br />Robert McClellon, RE.H.S. <br />Jeff Carruesco, R.E.H.S. <br />Linda Turkatte, R.E.H.S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name:, AlreA, My) PA" <br />Address: )1(1 Vos-44---1-4 <br />Contact Person: p AvinA <br />Phone #: 1 CO iç <br />Proposed Date of investigation/inspection: WO-11(7- <br />Description and brief narrative of inspection activity: <br />0 New UST installation Li UAR Investigation <br />0 Tank Closure in Place 0 Tank/Pipe Repair <br />0 Tank/Pipe Removal Li Re-excavation <br />0 Sampling 0 Boring / Monitoring Well installation <br />CI Hazardous Waste inspection 0 Tiered Permitting inspection <br />Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />Type of Operation: <br />Release History: <br />Evidence of leaks / soil contamination: YES CI NO <br />Documented Groundwater contamination: 0 YES 0 NO <br />Background and description of any previous investigation or incidence: <br />Potential Health & Safety Physical Concerns: (V all that apply & describe) <br />El Heat or Cold Stress: °F (high ambient temp.) <br />0 Noise Sources: <br />0 Oxygen Deficiency: <br />0 Excavation (falls, trips, slipping, cave-ins): <br />Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): <br />Confined space entry (explosions): <br />(24 Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />0 Other (specify): <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />raCarcinogens- <br />El Corrosives: <br />0 Dusts: <br />Explosives: <br />)3;) Flammables: <br />El Inorganic Gases: <br />0 Metals: <br />0 Oxidizers: <br />0 PCBs: <br />0 Other: <br />PART III <br />REQUIRED PERSONAL PRQTECTIVE EQUIPMENT <br />Monitoring Equipment (Not: Monitoring instruments must be used for all <br />operations unless appropriat rationale or restrictions are provided): <br />El Combustible Gas/Oxygen Meter <br />0 Detector Tubes (specify): <br />0 Photo ionization Detector <br />0 Organic Vapor Analyzer <br />0 Other (specify): <br />ID None (see below) <br />If monitoring instruments are not used, rationale or activity/area restrictions: <br />Personal Protective Equipment <br />Level of Protection: 0 A 0 B Li C D <br />0 Hard Hat <br />Safety Glasses/Goggles <br />Steel toed/shank shoes or boots <br />El Flame retardant coveralls <br />El Hearing protection <br />0 Tyvek <br />El Respirator: 0 APR 0 SCBA <br />A/P Cartridge: <br />Safety vest <br />Two-way communication <br />0 Other (specify): <br />Anticipated Biological Hazards: <br />V, Snakes 71, Insects 0 Rodents 0 Poisonous Plants <br />0 Other/Unknown (specify): <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: M Naidu <br />Plan Approved by: <br />Date: <br />Date: 1( I <br /> <br />EH 23081 (5/6/2011)