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SAN So�.QuIN COUNTY ENVIRON P TH DIVISION <br /> S7E HEALTH . SAFETY <br /> PART u <br /> PARI' I EVALUATION OF PO IFN I�AI.HAZARDS <br /> GENERAL SITE INFORMATION <br /> � �,4 C� Chemicals Hazards <br /> 1. Site Name: Sf a f; [] Carcinogens: <br /> Address: �S l C�'� `` "' ~ [L} Corrosives: <br /> Contact Person: , <br /> Phone No.�� [ ] Dusts• <br /> Sweeps number: Lr} Cpj-6 <br /> �, _�� � , ostves: <br /> Proposed Date of investigation inspection: Flammables: <br /> [ } inorganic Gases: <br /> 2. Description and brief narrative of inspection activity: [] Metals: <br /> [ ] New UST installation L ] UAR investigation [ ] Oxidizers: <br /> L ] Tank Closure in Place L ] Tw Pipe Repair []PCB's: <br /> [ ] <br /> Tank/Pipe Removal [ ] Re-excavation <br /> [ } installation of Borings/Monitoring Wells <br /> PART III <br /> REQLT�tE� PERSONAL PROTECTIVE3, Specific Site Information: EQUIPr, EIN~r <br /> Tank No. Tank Capacity. <br /> Tank Contents: Tank Age: _ 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 Gas/Oxygen Meter <br /> 5. Release History. [ } Detector Tubes (Specify) <br /> Evidence of leaks/soil contamination: E } YES [ } NO photoionization Detector <br /> Documented Groundwater contamination: [ ] YES [ ] NO L ]Or to is Va or Analyzer <br /> Background and description of any previous investigation Offer, 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 ppdescribe ) <br /> [ ] Heat or Cold Stress: patemp. 2, personal Protective Equipment <br /> [}'Noise Source: Leva1'of pfrotect%on: [ ]A [ ]B [ ]C [ ]D <br /> L ] Oxygen Deficiency: �j'Hardhat <br /> L ] Excavation: (falls, trips ,slipping, cave-ins)_ <br /> [ ] Handling and Transfer of a Hazardous Substance: [ } Safety glasses/goggles <br /> �[fiice{explosions, etc.) [ } Steel toed/shank shoes or boots <br /> Iosions) [ j Flame retardant coveralls <br /> E }._e6rifined Space entry: (exp Hearin protection <br /> [' Heavy equipment (physical injury& trauma resulting [j Hearing P <br /> from moving equipment) Tyvek <br /> [ } Respirator, circle: APR or SCBA <br /> [ } Other, specify A/P cartridge: <br /> [ } Safety vest <br /> 7. Anticipated Biological Hazards: <br /> [ ] Two-way communication <br /> [ } Snakes [ j Insects [ ] Rodents [ ] Poisonous Plants PART IV <br /> L ] other/Unknown (specify): PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health czXC,7 Date:' <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Dart Prepared by E�C c <br /> Plan Approved by: Date: <br /> E1423081 (2/7/92) <br />