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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH Al SAFETY PLAN <br /> PART I <br /> GENE, SITE INFORMATION PART II <br /> Z. Site Name: EVALUATION OF POTENTIA, HOARDS <br /> Address' I. <br /> Contact Chemicals Hazards <br /> Person: [ <br /> Sweeps Number. Phone No. ] Carcinogens; <br /> ------ [I Corrosives: <br /> Proposed Date of investigation/inspection: [ I Dusts: <br /> 2. Description and brief narrativef inspection activity: [ l Explosives: <br /> Of <br /> [I Flammables: <br /> [ I New UST Installation [ ] Inorganic Gases; <br /> [ I Tank Closure in Place [ I UAR Investigation <br /> [ I Tank/pipe[ Repair [I Metals:I Tank/Pipe Removal [ I Oxidizers: <br /> [ } InstalIatian of Bonn s [ ] Re-excavation <br /> g /Monitoring Wells I I PCB's: <br /> 3. Specific Site Information: PART III <br /> Tank No. Tank capacity:aci '' REQS PERSONAL PROTECTIVE <br /> Tank Contents: EQUIPMENT <br /> Other: Tank Age: <br /> Z. Monitoring Equipment: (note: Monitoring <br /> 4 Type of Operation: instruments must be used for all operations <br /> 5• Release History; <br /> unless appropriate rationale or restrictions are Evidence provided) <br /> of leaks/soil contamination: [ ] Combustible Gas/Oxygen Meter <br /> Documented Groundwater contamination: I I YES [ ] NO [ I NO Detector Tubes (Specify) <br /> Background and description of anI ] YES [ Ion [ I Photoionization Detector <br /> or incidence: Y previous uivestigation <br /> [l Organic Vapor Analyzer <br /> [ ] Other, specify <br /> If monitoring instruments are not used, <br /> b. Potential Health and Safety rationale or activity/area restrictions: <br /> Physical Concerns: (check all that apply& describe) <br /> [ I Heat or Cold Stress: of (high ambient temp.) <br /> I I Noise Source: <br /> I I Oxygen Deficiency: 2. Personal Protective Equipment <br /> [ I Excavation: (falls, trips ,slipping, cave-ins) Level of Protection: [ ]A [ ]B I IC [ ID <br /> [ l Handling and Transfer of a Hazardous Substance' [ I Hard hat <br /> (fire, explosions, etc.) [ I Safety glasses/goggles <br /> [ I Confined Space entry. {explosions) [I Steel toed/shank shoes or boots <br /> [ I Heavy equipment (physical injury & trauma resulting [ I Flame retardant coveralls <br /> from moving equipment) [ I Hearing protection <br /> [ I Tyvek <br /> [ I Other, specify [ ] Respirator, circle: APR or SOBA <br /> A/P cartridge: <br /> 7. Anticipated Biological Hazards: [ I Safety vest <br /> [ I Snakes I I Insects [ I Rodents [ ] Poisonous Plants [ I Two-way communication <br /> [ I Other/Unknown (specify): <br /> PART IV <br /> S. Narrative (provide alI information which could impact Health PLAN APPROVAL <br /> and Safety, e.g., power lines, integrity of dikes terrain, etc.): Pian Prepared by. Date: <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />