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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART H <br />GENERAL S11E IN/FORM�ATIoN , Q A F EVALUA ON OF POTENTIAL HAZARDS <br />1. Site Name: VQJI wV siVQQCJC �J/ v 1. �cals Hazards <br />Address: Ul. moge. <br />Contact Person: ou15 ShoA Phone No. b � [ ] osives: <br />Sweeps Number. PR? --3 i38Z m. <br />Proposed Date of investigation/inspection: (/iY! (L [ losives: <br />[ Flammables: <br />2. Description and brief narrative of inspection activity: [ ] Inorganic Gazes: <br />[ ] New UST Installation [ ] UAR Investigation [ ] Metals: <br />[] ank Closure in Place ( ] Tank/Pipe Repair [ ] Oxidizers: <br />[ Tank/Pipe Removal [ ] Re -excavation [ ] PCBs- <br />[ ] Installation of Borings/Monitoring Wells <br />PART III <br />3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br />Tank No. 0 1 d 02 Tank Capacity: EQUIPMENT <br />Tank Contenu:�� Tank Age: ZoyrS Bolin <br />Other. 1. Monitoring Equipment. (note: Monitoring <br />ins ents must be used for all operations <br />4. Type of Operation: f u� b Utt"" unIp§s appropriate rationale or restrictions are <br />pr 'ded) <br />S. Release History: Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: [ ] YES[ ] 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. Poteptial Health and Safety <br />Phy� Concerns: (check all that apply & describe) <br />VCN14 or Cold Stress: of (high ambient temp.) <br />[ ] Noise Source: 2. Perso Protective Equipment <br />[ l en Deficiency: Lev o rotection: [ ]A []B [ ]C <br />[y avation: (falls, trips ,slipping, cave-ins)Mt&eel <br />hat <br />[andling and Transfer of a Hazardous Substance: ty glasses/goggles <br />(fire, explosions, etc.) toed/shank shoes or boots <br />[ ] C9nfined Space entry. (explosions) [ ] Flame retardant coveralls <br />V11'eavy equipment (physical injury & trauma resulting [ ] Hearing protection <br />from moving equipment) [ ] Tyvek <br />[ ]Other, specify [ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />Safety vest <br />7. Anticipated Biological Hazards: (7 <br />[ ] Snakes [ ] Insects [ ] Rodents [ ]Poisonous Plants [ ]Two-way communication <br />[ ] Other/Unknown (specify): PART IV <br />PIAN 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 b y �I IV 1/= Date: i <br />Plan Approved by: Date: <br />EH23081 (2/7/92) <br />