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SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PIAN <br /> PART PART II <br /> EVALUATION OF POTENTIAL HAZARDS <br /> GENERAL SITE INFORL`�IATIO`3 <br /> M l 1. Chemicals Hazards <br /> 1. Site Name:,--) A> ' {]"Carcinogens: <br /> Address: [�,]'Eorrosives: <br /> Contact Person: (� 1SSC�Phone No. <br /> []Dusts: <br /> Sweeps Number: [}Explosives: <br /> Proposed Date of investigation/inspection: [x?Flamrnables: <br /> nic Gases: <br /> rga <br /> ] Ino <br /> 2. Description and brief narrative of inspection activity: [[yI Inorganic <br /> [}New UST Installation []UAR Investigation <br /> [] <br /> []Tank Closure in Place []Tank1Pipe Repair Oxidizers:[ ]PCB's: <br /> []TanklPipe Removal []Re-excavation <br /> []Installation of BoringsWonitoring Wells PART III <br /> 3.—Specific Site Information:"�T REQUIRED PERSONAL PROTECTIVE <br /> Taal:Capacity: EQUIPMENT <br /> Tank No. <br /> Tank Contents: Tank Age: <br /> 1. Monitoring Equipment:(note:Monitoring <br /> Other: instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> 4. Type of Operation: provided) <br /> []Combustible GaslOxygen Meter <br /> 5, Release History: [}Detector Tubes(Specify) <br /> Evidence of leaks/soil contamination: []YES []NO []DetectPhotoior Tubes <br /> Detector <br /> Documented Groundwater contamination: []YES [}NO []Organic Vapor Analyzer <br /> Background and description of any previous investigation []Other,specify: <br /> or incidence: 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.) 2. Personal Protective Equipment <br /> []Noise Source: bevel of Protection: []A [}B []C []D <br /> [] Oxygen Deficiency: }rlard hat <br /> []Excavation:(falls,trips,slipping,cave-ins) [ ` <br /> ��' fety glasses/goggles <br /> [,�'�andling and Transfer of a Hazardous Substance: Steel toed/shank shoes or boots <br /> (fire,explosions,etc.) []Flame retardant coveralls <br /> []Confined Space entry:(explosions) [,Nearing protection <br /> []Heavy equipment(physical injury&trauma resulting [}Tyvek <br /> from moving equipment) [I Respirator,circle: APR or SOBA <br /> A/P cartridge: <br /> []Other,specify [] Safety vest <br /> []Two-way communication <br /> 7. Anticipated Biological Hazards: <br /> []Snakes []Insects []Rodents []Poisonous Plants PART IV <br /> [}Other/Unknown(specify): PLAN APPROVAL <br /> S. Narrative(provide all information which could impact Health Plan Prepared by�' �Jvla -Date: <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Dater <br /> ER23081 (2/7/92) <br />