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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART <br /> GENERAL SITE INFORMATION PART II <br /> EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: <br /> Address: si £. s�=f s �� 1. Narciffinogens:s Hazards <br /> Contact Person: O{ / Tuti ,s `�`�" <br /> Phone No, s� a <br /> Sweeps Number: a a y osrves: <br /> Proposed Date of mvesngation/inspection: sts: <br /> L ] Explosives: <br /> 2. Description and brief narrative of inspection activity. [I Flammables: <br /> ( ] �New/�ST Installation [ ) UAR Investigation I ] Inorganic Gases: <br /> [ 1 ��nk Closure in Place [ ] Tank/pipe Repair L 7 Metals: <br /> [ Tank/Pipe Removal [ ] Re-excavation ( ] Oxidizers: <br /> [ I Installation of Borings/Monitoring Wells [1 PCB's: <br /> 3. Specific Site Information: PART III <br /> Tank No. a`r'1 jank Capacity: REQUIRED PERSONAL PROTECTIVE <br /> Tank Contents: .Lank Age: <br /> EQUIPMENT <br /> Other: <br /> 1. Monitoring Equipment: (note: Monitoring <br /> 4. Type of Operation: iMy K instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> S. Release History: pro ed) <br /> Evidence of leaks/soil contamination: [ � <br /> Combustible Gas/O <br /> ge <br /> Documented Groundwater contamination: I ] yES [9 NO xYfy) Meter <br /> [ ] NO I lDetector Tubes (Specify) <br /> Background and description of any previous investigation L I Photoionization Detector <br /> or incidence: //� f. J IF I Organic Vapor Analyzer= <br /> c s " S 3 L 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 /> ( at or Cold Stress: <br /> °F (high ambient temp.) <br /> [ Noise Source: <br /> L 1 Qxygen Deficiency: 2. Personal Protective Equipment <br /> [ EXCdVdtiOn: (falls, trips ,slipping, cave-ins) Level f Protection: [ ]A [ ]B [ ]C [ ]D <br /> [ I Handling and Transfer of a Hazardous Substance: [� hat <br /> (kine, explosions, etc.) L S ety glasses/goggles <br /> VJ Confined Space entry: (explosions) L steel toed/shank shoes or boots <br /> ( Heavy equipment (physical injury& trauma — [ I Flame retardant coveralls <br /> from moving equipment) resulting ( I Bearing protection <br /> [ ] Tyvek <br /> [ ] Other, specify_ 9a w r a of L s r [ 7 Respirator, circle: APR or SCBA <br /> Y 5 A/P cartridge: <br /> 7. Anticipated Biological Hazards: ( I Safety vest <br /> [ I Snakes [ ] Insects [ ] Rodents [ ] poisonous Plants L I Two-way communication <br /> L I Other/Unknown (specify): I r, by s ka Y+, ' r <br /> PART N <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc. : / <br /> Plan Prepared by: _L��,�"��/� Date: fIIS/j <br /> Plan Approved by "ICI L4 Date: . <br /> EH23081 (2/7/92) l� <br />