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f <br />a <br />I1 f <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />�i <br />PART I PART H <br />GENERA,, SITE INFORMATION EVALUATION OF POTENITAL HAzARDS <br />1. Site Name, <br />Address: <br />Contact Person --J <br />Sweeps Number: <br />Proposed Date of <br />Phone No. <br />2. Description and brief narrative of inspection activity: <br />[]Zik/P <br />UST Installation [ ] UAR Investigation <br />[ ]Closure in Place [ ] Tank/Pipe Repair <br />ipe Removal [ ] Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />3. Specific Site Information: n <br />Tank No. Z Tank Capacity. a -t <br />Tank Contents: Tank. Age: <br />Other: <br />4. Type of Operation: L„�1 <br />5. Release History: <br />Evidence of teaks/ oil contamination- WYES [ ] Or <br />Documented Groundwater contamination: [ ] YES (tNO <br />Background and description of any previous investigatio <br />or incid ce: GV 41inx -All a <br />6. Po�ical <br />Health and Safety <br />PF*c <br />s: all that apply & describe) <br />[S s: OF (high ambient temp.) <br />[:iency: <br />falls, trips ,slipping, cave-ins) <br />Transfer of a Hazardous Substance: <br />(hire, losions, etc.) <br />UleavW <br />ed Space entry: (explosions) <br />equipment (physical in]tuy & trauma resulting <br />m moving equipment) <br />llkdv,Other, specify L nl <br />7. Anticipated Biological Hazards: <br />[ ] Snakes [ ] Insects [ I Rodents [ I Poisonous Plants <br />[ I Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />EI -J23081 (2/7/92) <br />{ ] rrosives• <br />{ <br />[ losives• <br />II <br />[ sanmables: <br />[ ] Inorganic Gases: <br />[ j Metals: <br />[ I Oxidizers: <br />[ j PCB's: <br />PART M <br />': REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />i'lI. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />i� i unless propriate rationale or restrictions are <br />pro i ed) <br />[ Combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />{ ] Organic vapor Analyzer <br />�} (I Other, specify: <br />If monitoring instruments are not used, <br />' rationale or activity /area restrictions: <br />2. Perso Protective Equipment <br />Lev of otection: [ IA [ IB [ IC [ <br />ety glasses/goggles <br />Steel toed/shank shoes or boots <br />C]i Flame retardant coveralls <br />11:11 Hearing protection <br />p [ 17yvek <br />[ ] Respirator, circle: APR or SC3A <br />A/P cartridge: <br />[ j:Safety vest <br />[ ] Two-way communication <br />n3 <br />PART IV <br />PLAN APPROVAL <br />r <br />II''t <br />U� <br />[Plan Prepared by: Date: <br />Plan Approved by. n`^flate: <br />''i <br />