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OP4u�N C <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> •Qq<<FOR��p. SAN JOAQUIN COUNTY program Coordinators <br /> Donna K.DirectHeranor <br /> R.E. .S. Kase L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Y Y� <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Robert McClellon,R.E.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 /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 4; 1. Chemicals Hazards <br /> Address: ew- G. /-11,4- /Z ❑Carcinogens: <br /> Contact Person: tf'13 IILAO Corrosives: <br /> Phone#: X76 c7 ❑ Dusts: <br /> Proposed Date of investigation/inspe tion: '� ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation ❑ JAR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑ ank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ I te-excavation ❑PCBs: <br /> ❑Sampling ❑I loring/Monitoring Well installation ❑Other: <br /> yLa::Plazardous Waste inspection ❑Tiered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: ank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: ank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: O ,oma ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contaminatio : ❑YES ❑NO ❑None(see below) <br /> Documented Groundwater contamina ion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any p vious 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 ED <br /> ❑Heat or Cold Stress: (high ambient temp.) E Hard Hat <br /> ❑Noise Sources: E Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,c ve-ins): ❑Flame retardant coveralls <br /> _3landling and Transfer of a Hazar<ous Substance(fire,explosions,etc.):. E Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosions) ❑Respirator: ❑APR ❑ SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P Cartridge: <br /> equipment): E Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rode s ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information wh ch could impact Health and Safety, Plan Prepared b . Date: - L <br /> e.g.,power lines,integrity of dikes,to Tain,etc.): <br /> Plan Approved by: �U Date: I� <br /> EH 23081(6/26/2012) <br />