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PqU t ly <br /> �o.q�y.coa ii <br /> 2: ENVI OI&ENTAL HEALTH AARTMENT <br /> C��%FGitN;' SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.DirectHeranor <br /> R.E.H.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 I O ATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: lCarcinogens: A S'� �I 2 <br /> Contact Person: <br /> ❑Corrosives: <br /> Phone#: ❑Dusts: <br /> Proposed Date of investigation/insp tion: ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of in pection activity: ❑Inorganic Gases: <br /> ❑New UST installation ❑UAR Investigation ­aMetals: 1&2Q b, c l&S 0 S <br /> ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑Boring/Monitoring Well installation ❑Other: <br /> �Ilazardous Waste inspection El 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 /> ❑Detector Tubes(specify): <br /> 4. Type of Operation: r "{ ❑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 contam' tion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any I revious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety PhysicalConcerns:(✓all that apply&describe) Level of Protection: ❑A ❑B ❑C OD <br /> ❑Heat or Cold Stress: F(high ambient temp.) <br /> ®Hard Hat <br /> ❑Noise Sources: ®Safety Glasses/Goggles <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots <br /> ❑Excavation(falls,trips,slipping, ave-ins): ❑Flame retardant coveralls <br /> ❑Handling and Transfer of a H dour Substance(fire,explosions,etc.): ®Hearing protection <br /> ❑Tyvek <br /> ❑Confined space entry(explosion!): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical inj &trauma resulting from moving A/P Cartridge: <br /> equipment): ®Safety vest <br /> ❑Other(specify): ❑Two-way communication <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information 'ch could impact Health and Safety, Plan Prepared by: Date: v <br /> e.g.,power lines,integrity of dikes,I engin,etc.): <br /> v <br /> Plan Approved by: � Date: G / <br /> EH 23081(5/9/2011) <br />