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eSTS'rr rel,� <br /> SAN JOAQUIN COUNTY ENVIRONMEI]TAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PL Af�I <br /> PART I PART Ir <br /> GENERAL SITE Z <br /> INFORMATION c )VALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: kl&d a)(,k -Z, jAo_, 1. Chemicals Hazards <br /> Address: (] Carcinogens: <br /> Contact Person: Phone No. [] orrosives: <br /> Sweeps Number. XDusrs: <br /> Proposed Date of investigation/inspection: [ ] Explosives <br /> [I Flammables: <br /> 2. Description and brief narrative of inspection activity. [ ] Inorganic Gases: <br /> [ ] New UST Installation [J UAR Investigation [] Metals: <br /> [ ] Tank Closure in Place C Tank/Pipe Repair ( ] Oxidizers: <br /> ( ] Tank/Pipe Removal [ ] Re-excavation [] PCB's- <br /> [ J I�stalladon of Borings/Monitoring Wells. <br /> f.�'I 045kc G&nZllk;� t"�G`f7`GV`� PART III <br /> 3. Specific ue Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacivr. EQUIPMENT' <br /> Tank Contents: Tank Age: <br /> Other. 1. Monitoring Equipment. (note: Monitoring <br /> instruments musr be used for all operations <br /> 4. Type of Operatiorull i_. ..0/ unless appropriate rationale or restrictions are <br /> (� provided) <br /> S. Release History- [ ] Combustible Gas/Oxygen Meter <br /> Evidence of teaks/soil contamination: [ ] YES [ ] NO [ ] Derecror Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ J Phoroioaization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ ] Other, specify. <br /> If monitoring instrumenrs are nor used, <br /> rationale or activity/area restrictions: -&4JOrk <br /> Q <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all char apply& describe) <br /> [ j Heat or Cold Stress: of (high ambient ternp <br /> Noise Source: M .g"fw ;2 ,..YAm d 2. Personal Protective Equipment <br /> [ ] Oxygen Deficien Q V Level of Protection: [ ]A [ jB [ ]CD <br /> x5mmm"ri: , tri ,suppin , ) >4.Hard bar <br /> [ ] Handling and Traw r o a .azardous Substance: Safery giasses/goggles <br /> (fire, explosions, etc.) Steel coed/shank shoes or boors <br /> [ J Confined Space entry. (explosions) ( ] Flame retardant coveralls <br /> Heavy equipment (physical injury& trauma resulting Hearing protection <br /> wom moving equipment) Fon V Lit S. [ ] Tyvek <br /> Other, spe ( ] Respirator, circle: APR or SCBA <br /> city A/P cartridge: <br /> Gf}/11GS /�Hazards: <br /> Safety vesr <br /> 7. Anticipated Biolo [ ] Two-way communication <br /> ( ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART rV <br /> PLAN APPROVAL <br /> S. Narrative (provide all information which could impact Health } <br /> and Safety, e.gain <br /> ., power lines, integrity of dikes, terr , erc.): Plan Prepared b I' �I Date: <br /> Plan Aoproved by. Dare: <br /> EH23081 (2/7/92) <br />