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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I <br /> GENERAL SITE INFORMATION PART II <br /> p <br /> I. Site Name: EVALUATION OF POTENTIAL HAZARDS <br /> Address: 1. Ch icals Hazards <br /> Contact Person: Carcinogens: <br /> Sweeps Number: ..S p Phone No. + _ Z <br /> []C osives: <br /> Proposed Date of investigation/inspection: /65�_ Dust;: <br /> [1 osives: <br /> 2. Description and brief narrative of inspection activity: lammables: <br /> [] New UST Installation [I I rganic Gases: <br /> L] Tank Closure al Place [I UAR Investigation <br /> [I Tank/Pipe Repair VkMetals: <br /> K-Tank/Pipe RemovalRe-excavation [1 Oxidizers: <br /> [] Installation of Borings/Monitoring o []PCB's: <br /> 3. Specific Site Information: PART III <br /> Tank No.c?A1 /ism Tank Capacity: REQUIRED PERSONAL PROTECTIVE <br /> Tank Contents: t (L EQUIPMENT <br /> Other: �--- Tank Age: <br /> 1. Monitoring Equipment: (note: Monitoring <br /> 4. Type of Operation: bka g f a instruments must be used for all operations <br /> unless a propriate rationale or restrictions are <br /> 5. Release History: provi d) <br /> Evidence of leaks/soil contamination: [] YES [l] NO ombustible Gas/oxygen Meter <br /> Documented Groundwater contamination: [] YES [f NO [I Detector Tubes (Specify) <br /> investigation L] Photoionization Detector�� <br /> Background and description of any previous i <br /> or incidence: [IOrganic Vapor Analyzer <br /> [I Other, specify: —� <br /> If monitoring instruments are not used, <br /> 6. Potential Health and Safety rationale or activity/area restrictions: <br /> Physical Concerns: (check all that apply & describe) <br /> [ Heat or Cold Stress. —2.5 *F (high ambient temp.) <br /> MNoise Source: <br /> Oxygen Deficiency: 2. Personal I Protective Equipment <br /> D+Excavation: (falls, trips ,slipping, cave-ins) Level Protection: []A []B []C YTD <br /> (Handling and Transfer of a Hazardous Subs tan YJ-Kard hat `l <br /> (fire, explosions, etc.) ['1 Safety glasses/goggles <br /> [] Confined Space entry: (explosions) Leel toed/shank shoes or boots <br /> .I leavy equipment (physical injury & traum— a re [1 Flame retardant coveralls <br /> from moving equipment) [11 Hearing protection <br /> [I Tyvek <br /> [] Other, specify []�Pesplr,r, circle: APR or SCBA <br /> dge: <br /> 7. Anticipated Biological Hazards: st <br /> [I Snakes �Q Insects Rodents [] PoisonousPlants [1 Two-way communication <br /> [1 Other/Unknown (specify): <br /> PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL <br /> and Safi pt, e.g., power I Ce it, of dikes, terrain, etc.): Plan Prepared by: IBCA Date: <br /> ga '} -- <br /> n <br /> Plan Approved by: �[/� Date: <br /> EH23081 <br />