Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL- HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART U <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: • L G 1. Chemicals Hazards <br /> Address: �arcinogens• <br /> [- ]Corrosives: <br /> Contact Person: Phone No.. . <br /> Sweeps Number- [ ] Dust= <br /> Proposed Date of investiga 'on/inspection: [ ],Explosives: <br /> Iaminables: <br /> 2. Description and brief narrative of inspection activity: ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> [ ] Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> jank/Pipe Removal [ j Re-excavation []PCB's' <br /> [ j Installation of Borings/Monitoring Wells PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity. 3 y cD�° EQUIPMENT <br /> Tank Contents: QrTankAge: <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: � Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO [ j-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. Potential Health and Safety <br /> Ph Concerns; (check all that apply& describe) <br /> zn Jieat or Cold Stress: °F (high ambient temp.) <br /> Z <br /> Noise Source: Personal Protective Equipment <br /> �(��)TU,en Deficiency: Vmiard <br /> of Protection: [ ]A [ 1B � [ lD <br /> ation: (falls, trips ,slipping, cave-ins) hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes'or boots <br /> [ ] Co ed Space entry: (explosions) ] Flame retardant coveralls <br /> eavy equipment (physical injury&trauma resulting Hearing protection <br /> Tyvek <br /> from moving equipment} <br /> [lespirator, circle: R r �SCBA <br /> [ ] Other, specify 77 A/P cartridge: — H <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [] Two-way communication <br /> [ ] Snakes [ ] Insects [ 1 Rodents [] Poisonous Plants PART N <br /> [ ] Other/Unknown (specify): PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health .T Date•' ZJ,�` <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: <br /> Plan Approved by. 4 Date: <br /> EH23081 (2/7/92) <br />