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i <br /> ENVI ONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donn K Hera ,RE.H.S. Unit Supervisors <br /> N: rec 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> l Al Olsen,R.r.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> JDouglas W.Wilson,R.E.H.S. <br /> c P P gram M nager <br /> Telephone: (209)468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Cotull ,RE.H.S. Robert McClellon,R.E.H.S.Fax: (209) 464-0138 <br /> P gram M nager Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORM TION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:BACK ROAD--II--USTOM YCLE I. Chemicals Hazards <br /> Address:7939 W. 11TH STREET TRAY CA 95304 <br /> ❑Carcinogens: <br /> Contact Person:GEORGE MARTINEI Phone No:(209)839-0756 ❑Corrosives: <br /> Sweeps Number: I ®Dusts: <br /> Proposed Date of investiga' n/inspecti n:MAY 30.2003 ❑Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrati a of inspe tion activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑U R Investigation. ®Metals: <br /> ❑Tank Closure in Place. ❑Ta k/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re xcavation. ❑PCB's: <br /> ❑Installation of Borings/ onitoring ells. <br /> ®Hazardous Waste Inspec on ❑Sa ling. <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tan Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> _ <br /> operations unless appropriate rationale or restrictions are provided) <br /> Tank Content: Tan Age: <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:MOTOR YCLE RE AIR ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil conta ination: El YES [I NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater c tamination. ❑YES ❑NO <br /> Background and description o any previo s investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ND <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all at apply&describe) ®Safety Glasses/goggles. <br /> ®Steel toed/shank shoes or boots. <br /> ❑Hear or Cold Stress: °F(h' ambient temp.) <br /> ®Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> F1Excavation:(falls,trips,slipping,cave- s): El Tyvek. <br /> ElHandling and Transfer of a Hazardous ubstance:(fire,explosions, El Respirator: F-1 APR ❑SCBA <br /> etc..): iI A/P cartridge: <br /> F1 Confined space entry:(expltlsions): ®Safety vest. <br /> ❑Heavy equipment(physical injury&trama resulting from moving ®Two-way communication. <br /> equipment): I 1i <br /> ❑Other,specify PART IV-PLAN APPROVAL `/ <br /> 7. Anticipated Biological Hazards: Plan Prepared by: Date:js—/5 0 <br /> f Yr <br /> ❑Snakes ❑Insects ❑ odents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by: _/ Date: <br /> 8. Narrative(provide all informati which co Id impact Health and Safety, <br /> e.g.,power lines,integrity of dik s,terrain, tc.):UNKNOWN <br /> EH 23081 (12/17/2002) <br />