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� . 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> RT I PART II <br /> -NERAL SITE INFORMATION EVALUATION OF PO•IFMZAL HAZARDS <br /> Site Name: /Y7a1?o/e11 ivc� 2- T.%i 1. Chemicals Hazards <br /> Address: 629 Gov `se [I Carcinogens: <br /> SontactPerson: FW C<s�les Phone No. ZS<// (I Corrosives: <br /> Sweeps Number. /b 57 / [ ] Dusts: <br /> ?roposed Date of investigation/inspection: /1IGC.4 92 (�xplosives: <br /> �Tflammables• <br /> Description and brief narrative of inspection acdvicy: ( ] Inorganic Gases: <br /> ] New UST Installation [ ] UAR Investigation l+ ( ] Metals: <br /> ] Tank Closure in Place [ j Tank/Pipe Repair (] Oxidizers: <br /> �nk/Pipe Removal [ ] Re-excavation (]PCB's: <br /> ] Installation of Borings/Monitoring Wells <br /> PART III <br /> Specific Site Information: DOU REQUIRED PERSONAL PROTECTIVE <br /> Tank No.� Tank Capacity: � EQUIPMENT <br /> Tank Contents• rest/ Tank Age: ✓nK <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> instruments must be used for all operations <br /> Type of Operation- Artie /rte X 1 unless appropriate rationale or restrictions are <br /> provided) , <br /> Release HistoryI ] Combustible Gas/Oxygen Meter <br /> =_vidence of leaks/soil contamination: ( I YES C I N0 ( ] Detector Tubes (Specify) <br /> 3ocumented Groundwater contamination: ( ] YES MING H-Photoionization Detector <br /> 3ackground and description of any pre tyq_investigation [J Organic Vapor Analyzer <br /> :r incidence: /� [ ] Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> ?otential Health and Safety <br /> physical Concerns: (check all that apply & describe) <br /> ;- Heat or Cold Stress: of (high ambient temp.) <br /> •]-Noise Source: 2. Personal Protective Equipment <br /> I Oxygen Deficiency: Level of Protection: ( ]A ( JB ( ]C •[']'!S <br /> 14-E�-cavation: (falls, trips ,slipping, cave-ins) ('Hard hat <br /> ']-Handling and Transfer of a Hazardous Substance: [,L&afety glasses/goggles <br /> (fire, explosions, etc.) 1rlieel toed/shank shoes or boots <br /> ] Confined Space entry: (explosions) I ] Flame retardant coveralls <br /> ',,J-Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) ( ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> I ) Safety vest <br /> Anticipated Biological Hazards: [ J Two-way communication <br /> ( ] Snakes- [ ] Insects [ ) Rodents [ ) Poisonous Plants <br /> i ] Other/Unknown (specify): PART N <br /> PLAN APPROVAL <br /> Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date:p�-2-G-/ Z <br /> Plan Approved by Date: <br /> 12 <br />