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• • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: , I. Chemicals Hazards <br /> Address: l l/� S/ c7w� .n _ [] Carcinogens: <br /> Contact Person. 131st ur rah Phone No,lin &3/ [] Corrosives: <br /> Sweeps Number: PR.05 [ ] Dusts: <br /> Proposed Date of investigation/inspection: L/)C0 [ j Explosives: <br /> (] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> [ j Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> ( ] Tank/Pipe Removal [ ] Re-excavation <br /> []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> i-14z W 4S re,6 e'rloc � PART III <br /> 3. Specific Site Information: 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: �OLrAM, pG r�� �� unless appropriate rationale or restrictions are <br /> l a� G`�" S�Z provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ j 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 /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> );,_Heat or Cold Stress: CSO of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C �([D <br /> ( ] Excavation: (falls, trips ,slipping, cave-ins) Hard hat / ` <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, etc.) PIrSteel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) <br /> [ ] Flame retardant coveralls <br /> Heavy equipment (physical injury& trauma resulting 'D4� searing protection <br /> from moving equipment) L1 ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: N phi- [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by.& Date: <br /> Plan Approved by-_ (Cy 1Dater l <br /> EH23081 (2/7/92) �� <br />