Laserfiche WebLink
6 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION/ ^ ^ EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 6 (,(T-7 <br /> Address: (,O(W W ELL=yL 1. Chemicals Hazards <br /> ❑Carcinogens: <br /> Contact Person:J"00 N ?At" Phone No: ❑Corrosives: <br /> Sweeps Number: lq{mss . <br /> Proposed Date of investigation/inspection: ElExplosives: <br /> 2. Description and brief narrative of in ''Flammables: <br /> p inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation.. ❑DAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> Installation of Borings/Monitoring Wells. <br /> Hazardous waste inspection ❑ Sampling <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> //�� (� ,� <br /> El Detector Tubes(Specify). <br /> 4. Type of Operation: ABY� Tq I�t'�� a— ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: CIA ❑B ❑C ❑D <br /> 6. Potential Health and Safety ❑Hard Hat. <br /> Physical Concerns:(check all that apply&describe) �❑,rSafety Glasses/goggles. <br /> ❑Heat or Cold Stress: OF(high ambient temp.) �,I Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ❑Hearing protection. <br /> El Excavation: Tyvek.Excavation:(falls,trips,slipping,cave-ins): <br /> El Respirator: El APR El SCBA <br /> Handling and Transfer of a Hazardous Substance:(fire,explosions, A/P cartridge: <br /> ge: <br /> ❑Confined space entry:(explosions): ❑Safety vest. <br /> Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by V J. t V C` Date: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by: X Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,remain,etc.) <br /> EH 23081(02/19/03) <br />