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0 r, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. <br />Site Name: _M JSCA's S�U nr;x nq t ,y <br />1. Chepiials Hazards <br />Address: 2 9 5. )ac - <br />Carcinogens: <br />Contact Person: b M, sen Phone No. S,, 5-3 7/-5- <br />[ ] Corrosives: <br />Sweeps Number. /e/FZ <br />Proposed Date of investigation/inspection: /-S L5 <br />[ ] its: <br />[ ] E sives: <br />k'Flammables- <br />2. <br />Description and brief narrative of inspection activity: <br />[ ] Inorganic Gases: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Metals: <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ j Tattl�/Pipe Removal Re <br />[ ] Oxidizers: <br />[ ] -excavation <br />[ ] PCB's: <br />[ ] Installation of Borings/Monitoring Wells <br />PART III <br />3. <br />Specific Site Information: <br />REQUIRED PERSONAL PROTECMIE <br />Tank No. y y 2- o/ at a3 Tank Ca acity: Gr�� SfT (� ©� <br />'TL. <br />EQUIPMENT <br />Tank Contents:9,-v Tank Age: <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />4. <br />Type Operation: ` <br />instruments must be used for all operations <br />of C>-' <br />unless appropriate rationale or restrictions are <br />provided) <br />5. <br />Release History: <br />Evidence of leaks/soil <br />[ ] Combustible Gas/Oxygen Meter <br />contamination: [ I YES[ <br />Documented Groundwater contamination: YES NO <br />[ ] Detector Tubes (Specify) <br />[ ] <br />LTPhotoionization Detector <br />Background and description of any previous investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: <br />[ I Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />6. <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />mat or Cold Stress: I L7 °F (high ambient temp.) <br />[ ] Noise Source: <br />[ ] Oxy en Deficiency. <br />2. Personal Protective Equipment <br />Lev Protection: [ ]A [ ]B <br />[x vation: (falls, trips ,slipping, cave-ins) <br />})� <br />Hard hat <br />[�dling and Transfer of a Hazardous Substance: <br />(,]/Safety glasses/goggles <br />(fire, explosions, etc.) <br />[ -Steel toed/shank shoes or boots <br />[ ] Co ed Space entry: (explosions) <br />[ ] Flame retardant coveralls <br />eavy equipment (physical injury & trauma resulting <br />[ ] Hearing protection <br />from moving equipment) <br />[ ] Tytek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] Other, specify <br />A/P cartridge: <br />[ l Safety vest <br />7. <br />Anticipated Biological Hazards: <br />[ ]Two-way communication <br />[ ] Snakes [ ] Insects [ ] Rodents ]Poisonous Plants <br />[ <br />[ ] Other/Unknown (specify): <br />PART N <br />PLAN APPROVAL <br />S. <br />Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by �ge_ Date:/ -7 073' S` <br />Plan Approved by: 4 114— Date: <br />EH23081 <br />J > <br />(2/7/92)�� <br />