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PART II <br />EVALUATI <br />1. Chemical <br />Aarci <br />o COITO <br />El Dusts: <br />LI Explo <br />LI Flamn <br />LI Inorg <br />El Metal <br />Oxidi <br />El PCBs <br />Other <br />1. Site Name: <br />Address: <br />Contact Person: <br />Phone 1#: <br />Proposed Date of investigat <br />Tank Capacity. 1. <br />PART <br />REQUIRED <br />III <br />PERSONAL PROTECTIVE <br />Monitoring Equipment (Note: <br />operations unless appropriate <br />EQUIPMENT <br />Monitoring instruments must be used for all <br />rationale or restrictions are provided): Tank Age: <br />D Combustible Gas/Oxygen <br />D Detector Tubes (specify): <br />Photo ionization Detector <br />ID Organic Vapor Analyzer <br />Meter <br />oyk. <br />Specific Site Information: <br />Tank No.: <br />Tank Content: <br />Other: <br />Type of Operation: Mal( <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: <br />Plan Approved by: <br />Date 0 ) <br />Date: <br />ENVIRONMENTAL HEALTH DAARTMENT <br />Donna K. Heran, R.E.H.S. <br />Director <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />Web: www.sigov.orglehd <br />SITE HEALTH & SAFETY PLAN <br />Program Coordinators <br />Kasey L. Foley, R.E.H.S. " <br />Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S. <br />Linda Turkatte, R.E.H.S. <br />2. Description and brief narrative of inspection activity: <br />0 New UST installation El UAR Investigation <br />Tank Closure in Place 0 Tank/Pipe Repair <br />El Tank/Pipe Removal 0 Re-excavation <br />0 Sampling 0 Boring / Monitoring Well installation <br />R7ardous Waste inspection 0 Tiered Permitting inspection <br />N. OF POTENTIAL <br />; Hazards <br />ogens: frkel..) <br />HAZARDS <br />oaideal/faY6,.,4-- 1 <br />ives: <br />;ives: <br />iables: <br />nic Gases: <br />ters. <br />Release History: <br />Evidence of leaks / soil contamination: 0 YES 0 NO <br />Documented Groundwater contamination: D YES 0 NO <br />Background and description of any previous investigation or incidence: <br />Potential Health & Safety Physical Concerns: (.7 all that apply & describe) <br />1=1 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 />El Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />El Confined space entry (explosions): <br />D Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />0 Other (specify): <br />Anticipated Biological Hazards: <br />0 Snakes 0 Insects 0 Rodents 0 Poisonous Plants <br />El 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 />El Other (specify): <br />None (see below) <br />If monitoring instruments are not used, rationale or activity/area restrictions: <br />2. Personal Protective EquipmeI <br />nt <br />Level of Protection: 0 A 0 B 0 c El D <br />El Hard Hat <br />12?1 Safety Glasses/Goggles <br />El Steel toed/shank shoes or boots <br />El Flame retardant coveralls <br />El Hearing protection <br />Tyvek <br />El Respirator: D APR El SCBA <br />Al? Cartridge: <br />El Safety vest <br />El Two-way communication <br />0 Other (specify): <br />EH 23081 (6/14/2012)