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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Target Store 1. Chemicals Hazards <br /> Address: 4707 Pacific Ave <br /> ❑Carcinogens: <br /> Contact Person: Phone No: <br /> Corrosives: <br /> Sweeps Number: <br /> Dusts: <br /> Proposed Date of investigation/inspection: Jan 23,2006 explosives: <br /> 41Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ['3Qlazardous waste inspection El Sampling PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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 /> I ❑Detector Tubes(Specify). <br /> 4. Type of Operation: ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: F1 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 contamination: ❑YES ❑NO <br /> Background and description of any previous 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) gSafety Glasses/goggles. <br /> Steel toed/shank shoes or boots. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) b <br /> Flame retardant coveralls. <br /> ❑Noise Sources: <br /> ❑Hearing protection. <br /> ❑Oxygen Deficiency: <br /> ❑Tyvek. <br /> ❑ Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Respirator: El APR ❑SCBA <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): A/P cartridge: <br /> F]Confined space entry:(explosions): El Safety vest. <br /> El Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL rr 2'1, <br /> 7. Anticipated Biological Hazards: Plan Prepared by: Date: V v / b <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants (��,' C. <br /> ❑Other/Unknown(specify): Plan Approved by: Date: <br /> JV- <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (02/19/03) <br />