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% AlL. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PIAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: f'c �>�. 6 1. Chemicals azards <br /> Address: (' [ cinogens: <br /> Contact Person: Phone No..?D 1-t— r 1 Y f{ corrosives: <br /> Sweeps Number::?k b S i q1 Q a. - []Dusts: <br /> Proposed Date of investigation/inspection: []E losive." <br /> [ lammables. <br /> 2. Description and brief narrative of inspection activity: [] Inorganic Gases: <br /> []New UST Installation []UAR Investigation [,Metals: <br /> []Tank Closure in Place []Tank/Pipe Repair []Oxidizers: <br /> []Tank/Pipe Removal []Re-excavation [ ]PCB's: <br /> []I talla on of Borinp�sfMonitoring Wells <br /> u - &I PART III <br /> P <br /> 3.� 'ecific Site Inuformation: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment:(note:Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: Av—�) s L,r unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: [] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: []YES []NO []Detector Tubes(Specify) <br /> Documented Groundwater contamination: []YES []NO []Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: []Other,specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> b. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) <br /> []Ijeat or Cold Stress: °F(high ambient temp.) <br /> [$?Noise Source: 2. Personal Protective Equipment <br /> []Oxygen Deficiency: Le el of Protection: []A []B []C [JI> <br /> []E cavation:(falls,trips,slipping,cave-ins) [ and hat <br /> [y] iandling and Transfer of a Hazardous Substance: [ .4fety glasses/goggles <br /> (fire,explosions,etc.) . teel toed/shank shoes or boots <br /> []Confined Space entry:(explosions) [] Flame retardant coveralls <br /> []Heavy equipment(physical injury&traurna resulting [%44earing protection <br /> from moving equipment) _ []Tyvek <br /> [] Respirator,circle: APR or SCBA <br /> [] Other,specify A/P cartridge: <br /> [safety vest <br /> 7. Anticipated Biological Hazards: []Two-way communication <br /> [] Snakes []Insects [] Rodents []Poisonous Plants <br /> []Other/Unknown(specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health t (—O <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): Plan Prepared by: '4Date: <br /> Plan Approved by: Date:, <br /> EH23081 (2/7/92) <br />