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�,ytu ly. <br /> ENVIROAIENTAL HEALTH DOPARTMENT <br /> IFOfRd�'.. SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kase L.Fol R.E.H.S. <br /> Director 600 East Main Street, Stockton,California 95202 Y Foley, <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: V 1. Chemicals Hazards <br /> Address: 2C-1 ZZ . W . (, CL,10 K4 Yl Carcinogens: <br /> �""�� cj <br /> Contact Person: 7 , S 0517 Corrosives: " <br /> Phone#:_(='q)'�2-6�� `tb kj,Y771 ❑Dusts: <br /> Proposed Date of investigation/inspection: !3 JZ S 3 3D Z ❑Explosives: <br /> 19 Flammables <br /> 2. Description and brief narrative of inspection activity: $Inorganic Gases: h <br /> ❑New UST installation ❑UAR Investigation [3 Metals: �l��l Qh WUeA A-Y4 L,2.0 <br /> C]Tank Closure in Place C3Tank/Pipe Repair �Oxidizers: Yl U <br /> ❑Tank/Pipe Removal C1Re-excavation El PCBs: ��✓ <br /> ❑Sampling ❑Boring/Monitoring Well installation '&L Other: ( Q GtXIM <br /> azazdous Waste inspection ❑Tiered Permitting inspection atukN t-1 y1 <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided): <br /> Other: ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: / X �� ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence of leaks/soil contamination: ❑YES ❑NO None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous 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 ®D <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat <br /> XNNoise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> Excavation(falls,trips,slipping,cave-ins): C]Flame retardant coveralls <br /> V <br /> *andling and Transfer of a Hazardous Substance(fire,explosions,etc.):, ®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): ®Safety vest <br /> ❑Other(specify): Two-way communication PV U-PL. <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> makes Insectsf kodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared:!Tf� 7 <br /> Date: �7I2 <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved Date: 2� I <br /> EH 23081(3/5/2012) <br />