Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORINIATION EVALUATION OF POTENTIAL,HAZARDS <br /> 1. Site Name: �- 1. Chemicals azards <br /> Address: [ Carcinogens: <br /> Contact Person: n. Phone No. 13b leorrosives: <br /> Sweeps Number: []Dusts: <br /> Proposed Date of investigation/inspection: [] Ex losives: <br /> [ lammables: <br /> 2. Description and brief narrative of inspection activity: [] Inorganic Gases: <br /> []New UST Installation []UAR Investigation [y^tals: <br /> []Tank Closure in Place []Tank/Pipe Repair [] Oxidizers: <br /> []Tank/Pipe Removal []Re-excavation [ ]PCB's: <br /> [] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3r-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:_ Fc"> c �at-� A-} W-� unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: {] Combustible Gas'Oxygen Meter <br /> Evidence of leaks/soil contamination: [] YES [I 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 /> [I Heat or Cold Stress: 'F(high ambient temp.) <br /> [ oise Source: 2. Personal Protective Equipment <br /> []Oxygen Deficiency: Level of Protection: []A []B []C WD <br /> [] Excavation:(falls,trips,slipping,cave-ins) [Hard hat <br /> ,&,rHandling and Transfer of a Hazardous Substance: [u] Safety glasses/goggles <br /> (fire,explosions,etc.) M 6teel toed/shank shoes or boots <br /> [] Confined Space entry: (explosions) []Flame retardant coveralls <br /> []Heavy equipment(physical injury&trauma resulting [vj Hearing protection <br /> from moving equipment) []Tyvek <br /> [] Respirator,circle: APR or SCBA <br /> {] Other,specify AT 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 ��/_ � <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): Plan Prepared by:0, �l�a/?� Date:U- _—C20 <br /> Plan Approved by: / Date:ow <br /> EH23081 <br /> (2/7/92) <br />