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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DMSION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION ���� 0p /q�,� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: � Joa W)C 4 1. Chetpttals Hazards <br /> Address: [ arcmogens: <br /> Contact Person: 0 Yl Phone No.20 - -3y`✓b [IC osrves: <br /> Sweeps Number. 2 l Rarnnnables:s: <br /> Proposed Date of investigation/inspection: I� osives: <br /> 2. Description and brief narrative of inspection activity: [ J I rganic Gases: <br /> [ I New UST Installation ( ] UAR Investigation "etals: <br /> ( ] ank Closure in Place [ ) Tank/Pipe Repair [ ] dizers: <br /> (�]Tank/Pipe Removal [ ] Re-excavation [ PCB's: <br /> ( ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: r-.00 REQUIRED PROTECTIVE <br /> Tank No. - Tank Capacity: Q <br /> Tank Contents: 0,5te- Tank Age: 1/MK, <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: � U n[ r cb1 L q e�Ai)) unles appropriate rationale or restrictions are <br /> /v]��hiri t S pro ded) <br /> S. Release History: Combustible Gas/Oxygen Meter <br /> Evidence of leaks/sail contamination: [ ] YES [ [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ I YES [ NO [ J 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. Pote al Health and Safety <br /> Ph ica, Concerns: (check all that apply& describe) <br /> e or Cold Stress: of (high ambient temp.) <br /> [ ] F_andling <br /> . Source: 2- Perso al Protective Equipment <br /> [ ] en Deficiency: Lev o Protection: [ ]A [ ]B [ ]C <br /> [ ation: (falls, trips ,slipping, cave-ins) hat <br /> [ and Transfer of a Hazardous Substance: ety glasses/goggles <br /> 9l explosions, etc.) Steel toed/shank shoes or boots <br /> [ ] nfined Space entry: (explosions) ] Flame retardant coveralls <br /> eavy 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 /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ I Insects [ I 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.): Plan Prepared by. Date: (f/ <br /> Plan Approved by: DateQ <br /> EH23081 (2/7/92) <br /> 10.4 <br />