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2• ENVIRONMENTAL HEALTH DEPARTMENT <br /> . Foa� • Donna K.Heran,R.E. .S. SAN JOAQUIN COUNTY Program Coordinators <br /> Director 600 East Main Street, Stockton, California 95202 Kasey L.Foley,R.B.H.S. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Robert McClellon,RE.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: wI G �~ 1. Chemicals Hazards <br /> Address: 5n4C7 1 + r ❑Carcinogens: <br /> Contact Person: iM ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigatiott/inspec'on: ❑Explosives: <br /> _j9+Flammables'---n <br /> 2. Description and brief narrative of insp tion activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑L AR Investigation ❑Metals: <br /> ❑Tank Closure in Place ❑ ipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑ -excavation ❑PCBs: <br /> ❑Sampling ❑B oring/Monitoring Well installation ❑Other: <br /> '2'Hazardous Waste inspection ❑ ered Permitting inspection <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: T ink Capacity: 1. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank Content: T ink Age: operations unless appropriate rationale or restrictions are provided): <br /> Other ❑Combustible Gas/Oxygen Meter <br /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: / C�ti ❑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 contaminati n: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pre fious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety F hysical Co terns:(✓all that apply&describe) Level of Protection: [IA ❑B [IC OD <br /> ❑Heat or Cold Stress: OFhigh ambient temp.) ®Hard Hat <br /> ❑Noise Sources:— <br /> ®Safety Glasses/Goggles <br /> C]Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips, lipping,care-ins): C]Flame retardant coveralls <br /> Handling and Transfer f a Hazard Substance(fire,explosions,etc.):. ®Hearing protection <br /> ❑Tyvek <br /> Confined space entry( plosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physJ cal injury trauma resulting from moving <br /> A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Haz,rds: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(speci ): PLAN APPROVAL / <br /> 8. Narrative(provide all infort ution whit i could impact Health and Safety, Plan Prepared by: i`;' Date: Z Z— <br /> e.g.,power lines,integrity dikes,t in,etc.): ✓j ( � n r� <br /> Plan Approved by: Date: I I v <br /> EH 23081(4/12/2012) <br />