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z s ENVIROENTAL HEALTH AARTMENT <br /> •c��,FORa�' <br /> Donna K.Heran,R.E.H.S. SAN JOAQUIN COUNTY program Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.E.H.S. <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Robert McClellon,R.E.H.S. <br /> J <br /> Web:www.sjgov.org/ehd effCarruesco,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE IORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: � 1. Chemicals Hazards <br /> Address: ?/l O 6)y;; Carcinogens: <br /> Contact Person�P n1 bgf!J Sl?�x�s Phone#: ' El❑Corrosives: <br /> Envision#(s): Dusts: !Z)g� <br /> Proposed Date of investigation/inspection: t) ❑Explosives: <br /> Flammables: _� <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation 1°jI Metals: <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation Other: 0;161 <br /> , <br /> Hazardous Waste inspection ❑Tiered Permitting inspection <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 /> J�y�/ /�/,/— ��y(� �j�p ❑Detector Tubes(specify): <br /> 4. Type of Operation:J/��`fi�/ ✓✓�'ty1 'N /I'�►" trY� ❑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(highar nt temp.) ®Hard Hat <br /> Noise Sources: ��i (/( �S ®Safety Glasses/Goggles <br /> El Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping,cave-ins): El Flame retardant coveralls <br /> C]Handling 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): h5 ElTwo-waycommunication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL r <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Prepared by: Dat�J W <br /> e.g.,power lines,integrity of dikes,terrain,etc.): n, <br /> Plan Approved by: 1` Date:� tT <br /> EH 23081(3/18/2010) <br />