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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHOISION <br /> SITE HEALTH AND SAFETY PLAN <br />'ART I PART II <br />;ENEItAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />,. Site Name: 1. Chemicals Hazards <br /> [J Carcinogens: <br /> Address: <br /> Contact Person: Phone No. (] Corrosives: <br /> Sweeps Number. [ ] Dusts: <br /> Proposed Date of investigation/inspection: [ ] Explosives: <br /> [] Flammables: <br /> Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation ( ] UAR Investigation [] Metals: <br /> ( ] Tank Closure in Place ( ] Tank/Pipe Repair ( ] Oxidizers: <br /> [ ] 's: <br /> Tank/Pipe Removal [ ] Re-excavation [] PCB <br /> [ ] Installation of Borings/Monitoring Wells PART III <br /> Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capaciry: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Ocher: 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 /> provided) <br /> 5. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES ( ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: ( ] YES ( ] NO [ J Photoionization Detector <br /> Background and description of any previous investigation [J Organic Vapor Analyzer <br /> or incidence: [ ] Other, specify: <br /> If 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 [ JB ( ]C [ ID <br /> ( ) Excavation: (falls, trips ,slipping, cave-ins) [ ] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: ( ] Safety glasses/goggles <br /> (fire, explosions, etc.) [ ] Steel coed/shank shoes or boots <br /> Flame retardant coveralls <br /> ( ] Confined Space entry: (explosions) [ ] Hearin protection <br /> [ J Heavy equipment (physical injury & trauma resulting ( l g P <br /> from moving equipment) [ J 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 /> [ ] <br /> Snakes,- [ ] Insects ( ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <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: <br /> Plan Approved by:' Date: <br /> 12 <br />