Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PIAS] <br />PARTI PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: On f <br />Address: <br />Contact Person: u A li-_0en Y).l ]-Phone No. S9S- 3o3s <br />Sweeps Number. / (I k1 <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [) Tank/Pipe Repair <br />H iank/Pipe Removal [] Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />Chemicals Hazards <br />[ ] Carcinogens- _ <br />[ ] Corrosives: <br />( ] Dusts: <br />[ ] osives: <br />[ lammables: <br />[ ] Inorganic Gases: <br />(] Metals: <br />[ ] Oxidizers: <br />[ J PCB's: <br />PART III <br />3. <br />Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. I yg/ - o l Tank Capacity: 10, 6100 <br />EQUIPMENT <br />Tank Contents: 426, csc / Tank Age: v n k <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />4. <br />Type of Operation: Wo s %t A — [� F [ i dL <br />unless appropriate rationale or restrictions are <br />provided) <br />S. <br />Release History: <br />( ] Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: (I YES [-J'fv0 <br />[ I Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES [,J -NO <br />[r"hotoionization Detector <br />Background and description of any previous investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: 'fo4C_ <br />(] 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 />[�- eat or Cold Stress: of (high ambient temp.) <br />[ ] Noise Source: <br />2. Personal Protective Equipment <br />[ ] 0 gen Deficiency: <br />Level of Protection: [ ]A [ ]B [ ]C [']I5— <br />( xcavation: (falls, trips ,slipping, cave-ins) <br />[.]'Hard hat <br />[(]'handling and Transfer of a Hazardous Substance: <br />[safety glasses/goggles <br />(fire, explosions, etc.) <br />[feel toed/shank shoes or boots <br />(] Confined Space entry: (explosions) <br />[ I Flame retardant coveralls <br />[XFTavy equipment (physical injury & trauma resulting <br />[ ] Hearing protection <br />from moving equipment) <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] Other, specify <br />A/P cartridge: <br />[ ] Safety vest <br />7. <br />Anticipated Biological Hazards: <br />[ ] Two-way communication <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />8. <br />Narrative (provide all information which could impact Health <br />lines, integrity dikes, <br />Plan Prepared by. Date: <br />and Safety, e.g., power of terrain, etc.): <br />Plan Approved by, Date: <br />EH23081 (2/7/92) <br />40 <br />