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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL.HAZARDS <br /> 1. Site Name: ' '`'' ✓ 1. cals Hazards <br /> Address: z "_c' /_ ` ' [Ch Carcinogens: <br /> Contact Person: \, P .` = t` Phone No. z'j=; 116= []Corrosives: <br /> Sweeps Number. S [ ] Dusts: <br /> Proposed Date of investigation/inspection: 3�k I I`; ( ] Explosives: <br /> [jTlammables: <br /> 2. Description and brief narrative of inspection activity. [ ] Inorganic Gases: <br /> [ J New UST Installation [ ] UAR Investigation [ ] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair ( ] Oxidizers: <br /> N[ Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity F' ✓ ' EQUIPMENT <br /> Tank Conten Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: y r e unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [a'NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [)NO (I'Pliotoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ ] Other, specify- <br /> If <br /> pecifyIf 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: OF (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C [-IT)F, <br /> [ ]-Excavation: (falls, trips ,slipping, cave-ins) (.1-Hard hat <br /> []'Handling and Transfer of a Hazardous Substance: [.1 Safety glasses/goggles <br /> (fire, explosions, etc.) [ ] Steel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> 1-1-Heavy equipment (physical injury& trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] T'r'ek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ J Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health _7 <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by. Date: <br /> Plan Approved by�� Date7 Cllr <br /> EH23081 (2/7/92) <br />