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SAN JOA.QUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals ards <br /> Address: ` l V Car inogens: - <br /> Contact Person: �,fMi l' k $Ane No. Cit [ orrosives: <br /> Sweeps Number: []Dusts: <br /> Proposed Date of investigation/inspection: E J E losives: <br /> Varnmables: <br /> 2. Description and brief narrative of inspection activity: []In,pfganic Gases: <br /> []New UST Installation []UAR Investigation [- etals: <br /> []Tank Closure in Place []Tank(Pipe Repair [] Oxidizers: <br /> [J Tank/Pipe Removal []Re-excavation [ ]PCB's: <br /> [])ftstallation of Borings/Monitoring Wells <br /> PART III <br /> �.�..� �''c Site Information:• L� ��lr„1'�=�'7�� f <br /> 3. pecifiREQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note:Monitoring <br /> �j instruments must be used for all operations <br /> 4. Type of Operation: tC CSI '� '� unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: [] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: []YES []NO []Detector Tubes(Specify) <br /> Documented Groundwater contamination: []YES []NO []Photoionization Detector <br /> Background and description of any previous investigation [J Organic Vapor Analyzer <br /> or incidence: [] Other,specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply&describe) <br /> []Heat or Cold Stress: °F(high ambient temp.) <br /> ['Noise Source: 2. Personal Protective Equipment <br /> [] Oxygen Deficiency: Lev 1 of Protection: []A []$ []C V <br /> [J E vation: (falls,trips,slipping,cave-ins) [ d hat <br /> fV114andling and Transfer of a Hazardous Substance: [, afety glasses/goggles <br /> (fire,explosions,etc.) [,Steel toed/shank shoes or boots <br /> []Confined Space entry:(explosions) []Flame retardant coveralls <br /> [J Heavy equipment(physical injury&traurna resulting �J'flearing protection <br /> from moving equipment) []Tyvek <br /> []Respirator,circle: APR or SCBA <br /> [] <br /> Other,specify A/P artridge: <br /> afety vest <br /> 7. Anticipated Biological Hazards: []Two-way communication <br /> [] Snakes []Insects []Rodents []Poisonous Plants <br /> [J Other/Unknown(specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): Plan Prepared by:\) �j <br /> "O Va" Date: /'� <br /> Plan Approved by: Date 1 <br /> EH23081 (217192) <br />