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SAN JOAQUIN COUNTY EiNVMON-MEN TAI, 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: !,,/�- -5 " - 1. Chemicals Hazards <br /> Address: < 'c S< []Carcinogens: <br /> Contact Person ? eN [] Corrosives: <br /> Sweeps Number: ?,, %S ( ] Dusts: <br /> Proposed Date of investigatior/inspection: [ ] Explosives: <br /> [�]Plammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ J New UST Installation [ ] UAR Investigation [-]Metals: <br /> [6YTank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation [J PCBs: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. / Tank Cap aci r 'a' Q <br /> Tank Contents: . �''; '; [ iTa Ag—'-- E UIPMENT <br /> Other: 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: [ I YES [TNO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ I NO [ ] Photoicnization 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. Potential Health and Safety <br /> Physical Concerns: (check all that apply& describe) _ <br /> [I Heat or Cold Stress: of (high ambient temp.) <br /> [a Noise Source: 2 Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: <br /> [ ]A [ ]B [ ]C [ ]D <br /> [-I Excavation: (falls, trips slipping, cave-ins) [] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [I-Safety glasses/goggles <br /> Rre, explosions, etc.) [-] Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [,]'Meavy equipment (physical injury& trauma resulting I-] Hearing protection <br /> from moving equipment) [ I Tyvek <br /> [ <br /> [ ] Respirator, circle: APR or SCBA <br /> ] Other, specify <br /> A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL <br /> and Safety, e.g., power lines, integrity of(likes, terrain, etc.): PlanPrepared by L (,.G% ' Date: <br /> Plan Approved by: Ay fie_ . Date: a-14A <br /> ER23081 (2/7/92) <br />