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SAN JOAQUIN COU'-rY ENVIRONMENTAL HEALTH '_,!'VISION <br /> SITE HEALTH AND SAFETY PLAN <br /> ' PART II <br /> ART I <br /> EVALUATION OF POTENTIAL HAZARDS <br /> GENERAL SITE INFORMATION <br /> Vesl' 1. Chemicals Hazards <br /> Site Name: (] Carcinogens: <br /> M G <br /> Address: IID rr <br /> Contact Persons I u A Phone No. �—Z 2. (] Corrosives: <br /> 4(�3 <br /> ( ] Dusts: <br /> Sweeps Number: N [ ] Explosives: <br /> Proposed Date of investigation/inspection: 7G (] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [I] N UST Installation ( ] UAR Investigation [ ] Metals: <br /> Tank/Pi a Re air [ ] Oxidizers: <br /> nk Closure in Place [ ] p p PCB's: <br /> nk/Pipe Removal [ ] Re-excavation I) <br /> ( ] Installation of Borings/Monitoring Wells PART Ill <br /> 3. Specific Site information: () �� REQUIRED PERSONAL PROTECTIVE <br /> Tank Ca aci I EQUIPMENT <br /> Tank No. P n 3 <br /> Tank Contents: Tank Age: <br /> 1. Monitoring Equipment: (note: Monitoring <br /> Other: instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> ( ] Combustible Gas/Oxygen Meter <br /> S. Release History: YES ( ] NO [ ] Detector Tubes (Specify) <br /> Evidence leaks/soil contamination: [ ] Photoionization Detector <br /> Documented Groundwater contamination: [ ] YES [ ] NO ( J organic Vapor Analyzer <br /> Background and description of any previous investigation [] Or 8 P n <br /> [ ] Other, 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 & describe) <br /> ( ] Heat or Cold Stress: °F (high ambient temp.) 2 persona Protective Equipment <br /> [ J Noise Source: Leve f Protection: ( ]A ( ]B ( IC [ ]D <br /> [ ] Oxygen Deficiency: [ and hat <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) Safeglasses/goggles <br /> [ ] Handling and Transfer of a Hazardous Substance: ] Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) [ ] Flame retardant coveralls <br /> [ ] Confined Space entry: (explosions) sulting Hearing protection <br /> [ ] Heavy equipment (physical injury & trauma reHeari g P <br /> from moving equipment) Tyvek <br /> ( ] Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> ( ] Other, specify ( ] Safety vest <br /> 7. Anticipated Biological Hazards: <br /> ( I Two-way communication <br /> [ ] Snakes. ( ) Insects [ ] Rodents ( ] Poisonous Plants PART [V <br /> [ ] Other/Unknown (specify): PIAN APPROVAL ���" <br /> 8. Narrative (provide all information which could impact Health Dater - - "I <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: W <br /> Plan Approved by:' qee Date <br /> 12 <br />