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OP.QU.JI <br /> ENVI OOMENTAL HEALT#DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> cq' • �P Donna K.Heran E.H. . Program Coordinators <br /> �rFoe�' S 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Director Huggins,iR.E.H.S. <br /> Laurie A.Cotulla, R.E.H.S. Stockton, California 95202 Mike Hu ,R.D.I. <br /> Assistant Director Telephone: (209)468-3420 Kasey L.Foley,R.E.H.S. <br /> Margaret Lagorio,R.E.H.S. <br /> Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Web: www.sjgov.org/ehd Jeff Carruesco,R.E.H.S. <br /> SI'Z'E HEALTH&SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION // EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: a1 o� 1. Chemicals Hazards <br /> Address: PaCarcinogens: <br /> Contact Person:S P1 one No: 7Z-Q-G►—U 4-1 1*Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/insp tion: L 1 � Z Explosives: <br /> T�Flaminables: <br /> 2. Description and brief narrative of insl ection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place.. ❑I k/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑ e-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoril Wells. <br /> M Hazardous waste inspection ❑ Sampling <br /> ❑Tiered Permitting inspection 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: ank Age: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation: a4, ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamina on: ❑YES ❑NO <br /> Background and description of any prt vious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑ B ❑C ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,c ve-ins): <br /> ❑Tyvek. <br /> Handling and Tians>;er of a Hazardous Substance:(fire,explosions, El Respirator: ❑APR El SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space envy:(explosions): ®Safety vest. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify: PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by: M Naidu Date: <br /> ❑Snakes %insects ❑Rodent ❑Poisonous Plants <br /> ❑Other/Unknown(specity): Plan Approved b I <br /> PP Y� Date: v <br /> 8. Narrative(provide all information whie could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terr iin,etc.) <br /> EH 23081(02/19/03) <br />