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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: � /'— 1. 9 icals Hazards <br /> Address: b /o - l�uG�l�se IE'/�- r [ g0ccinogens: <br /> Contact Person: 9 w� Phone No. $-6 2�1 [rCorrosives: <br /> Sweeps Number: 4 1 78 -o J I [ J 9tsts: <br /> Proposed Date of investigation/inspection: ( osives: <br /> [ lammables• <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [ ] Metals: <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 /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. ® 1 Tank Capacity: ?j- e yea EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ,p,�., instruments must be used for all operations <br /> 4. Type of Operation: "'" 1 unless appropriate rationale or restrictions are <br /> provide <br /> S. Release Historyombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ J 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: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level f Protection: [ ]A [ ]B [SIC {ru <br /> VTtxcavation: (falls, trips ,slipping, cave-ins) ( d hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] ety glasses/goggles <br /> (fire, explosions, etc.) [ Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury& trauma resulting [ wring protection <br /> from moving equipment) [ k <br /> [ YfLespirator, circle: or SCBA <br /> [ ] Other, specify A/P cartridge: G <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: ( ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PIAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health 2 <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by _.. ._' Date: Z <br /> Plan Approved by: yi:iz Date: --5-x13 <br /> EH23081 (2/7/92) <br />