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0 <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I <br />GENERAL SITE <br />1. Site Name: S -F L cc) 5 ue 4 4 <br />Address: y// S• Sic/ {r o <br />Contact Person: f/c,/ L4wilrlct Phone No -f 2Y6% <br />Sweeps Number: z SG S <br />Proposed Date of investigation/inspection: l.' y'2' <br />2. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[,J-1`a`nk/Pipe Removal [ ] Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. <br />Chemicals Hazards <br />(carcinogens: <br />[ ] Corrosives: _ <br />[ J Dusts: <br />losives: <br />VI Flammables _ <br />[ ] Inorganic Gases: <br />[ ] Metals: <br />[ ] Oxidizers: _ <br />[ ] PCB's: <br />PART III <br />3. <br />Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. a / Tank Capacity: �,, c Z' <br />EQUIPMENT <br />Tank Contents: Tank Age: &ra A - <br />Other: <br />I. Monitoring Equipment: (note: Monitoring <br />4. <br />� / //', <br />Type of Operation: / ©rr54Ic A,c»t �� - <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />5. <br />Release History: <br />[ ] Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: [ J YES [1146- <br />[ I Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES [i Ib'O <br />[ rPPhotoionization 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 />[ ] Heat or Cold Stress: of (high ambient temp.) <br />[,-Noise Source: <br />2. Personal Protective Equipment <br />[ ] Oxygen Deficiency: <br />[ J-I�X-cavation: (falls, trips cave-ins) <br />Level of Protection: [ ]A [ ]B [ ]C [ <br />[.]'AI d hat <br />,slipping, <br />[ Handling and Transfer of a Hazardous Substance: <br />fety <br />[ glasses/goggles <br />(fire, explosions, etc.) <br />[.-Steel toed/shank shoes or boots <br />[ ] Confined Space entry: (explosions) <br />[ Heavy equipment (physical injury & trauma resulting <br />[ ] Flame retardant coveralls <br />-Hearing <br />W protection <br />from moving equipment) <br />[ ] Tyvek <br />[ ] Other, specify <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />[ J Safety vest <br />7. <br />Anticipated Biological Hazards: <br />[ I 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 />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by- Date: '3 /%' 7FZ <br />Plan Approved by -Date, <br />EH23081 (2/7/92) <br />