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S, N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> RT I PART II <br /> \ZMiLL SITE INFORP CATION EVALUATION OF POT&VnAL HAZARDS <br /> Site Name: to /< C,,.j lf,) 1. C)zemicals Hazards <br /> Address: 1n5cro S F#arlo R.( `t [✓f Carcinogens. <br /> :ontactPerson: Rev Uinov.'cL Phone No. eZ 835— ?-/7 [] Corrosives: <br /> Sweeps Number- � J11 [ J Dusts. <br /> ?-oposed Date of investigarion/inspecrion: [ ) Explosives: <br /> [dFlammables: <br /> Description and brief narrative of inspection activity. [ J Inorganic Gases: <br /> J New UST Installation [ ) UAR Investigation [ ] Metals: <br /> Tank Closure in Place [ ] Tank/Pipe Repair ( ] Oxidizers: <br /> [eank/Pipe Removal [ ] Re-excavation [) PCB's: <br /> J Installation of Borings/Monitoring Wells <br /> PART Ill <br /> Soecit"ic Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> 'ank Contents: Tank Age: <br /> ocher: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> Type of Operation: �/�s l �� S�t����/�'^ unless appropriate rationale or restrictions are <br /> provided) . <br /> 2elease History ✓ [y Combustible Gas/Oxygen Meter <br /> ;vidence of leaks/soil contamination: [ ] YES [7�IO 0 ( ] Detector Tubes (Specify) <br /> (�r <br /> 7ocumented Groundwater contamination: ( ] YES N ( ) Photoionization DetectorOr Organic Vapor Analyzer <br /> 3ackground and description of any previous investigation [] g P <br /> [ ] Other, specify <br /> x incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> ?ocential'Health and Safety <br /> ahysical Concerns: (check all that apply & describe) <br /> ] ]'Heat or Cold Stress: of (high ambient temp.) 2 Personal Protective Equipment / <br /> ] Noise Source: Level of Protection: ( ]A ( )B [ ]C j- D <br /> ] Oxygen Deficiency: [ ] Hard hat <br /> J Excavation: (falls, trips ,slipping, cave-ins) <br /> ] Handling and Transfer of a Hazardous Substance: [ J Safety glasses/goggles <br /> (fire, explosions, etc.) ( ) Steel toed/shank shoes or boots <br /> [ ] Flame retardant coveralls <br /> ] Confined Space entry: (explosions) Hearin protection <br /> ; ) Heavy equipment (physical injury & trauma resulting [ ) g <br /> from moving equipment) [ ) Tyvek <br /> [ ) Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> [ ) Other, specify [ J Safety vest <br /> Anticipated Biological Hazards: <br /> [ ] Two-way communication <br /> [ ] Snakes. [ ) Insects O Rodents ( ] Poisonous Plants1. PART N <br /> i ) other/Unknown (specify): PLAN APPROVAL <br /> Narrative (provide all information which could impact Health plan Prepared by: Akn� Date: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br /> Plan Approved by Dare: �/Z 7�Jm- <br /> 12 <br />