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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: 1. Chemicals Hazards <br /> Address: i <br /> cinogens: <br /> Contact Person:f/( rTdr ! az <br /> S Phone No.__J� rrosives: <br /> Sweeps Number. ( ] usts' <br /> Proposed Date of investigation/inspection: Explosives: <br /> lammables• <br /> 2. Description and brief narrative of inspection activity: (1,,knorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [ ] Metals: <br /> [ ] Tank Closure in Place ( ] Tank/Pipe Repair [ ] Oxidizers: <br /> ,( ank/Pipe Removal [ ] Re-excavation []PCB's: <br /> TInstallation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity. EQUIPMENT <br /> Tank Contents: Tank Age: <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 /> prCo <br /> vided) <br /> 5. Release History. mbustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YESkaon <br /> O [ Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ j YESO [ ) Photoionization Detector <br /> Background and description of any previous investi (] Organic Vapor Analyzer <br /> or incidence: ( j Other, specify <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> ical Concerns: (check all that apply& describe) <br /> rViear or Cold Stress: of (high ambient temp.) <br /> Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: ( ]A ( ]B [WC 'KD <br /> Excavation: (falls, trips ,slipping, cave-ins) azd hat <br /> Handling and Transfer of a Hazardous Substance: afety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boots <br /> ] Confined Space entry: (explosions) [ Flame retardant coveralls <br /> Heavy equipment (physical injury& trauma resulting Hearing protection <br /> from moving equipment) Tyvek <br /> PRespiracor, circle. APR SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects ( ] Rodents ( ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART N <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): PlanPrepared by: C -7 Date: <br /> Plan Approved by. Date: <br /> EH23081 (2/7/92) <br />