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• 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND`SAFETY PLAN <br /> PART I PART U <br /> GENERAL SITE MFORMA/T)ION 1 , EVALUATION OF POTENTIAL.HAZARDS <br /> 1. Site Name: �? Y� (�c ,i P/ `, 1. Chemicals Hazards l;0 c_pat�L, <br /> Address: e:e; 1 "r +o-n K6) []-Carcinogens: <br /> Contact Person: Scctl G, :,n r„Kn Phone No. i,6 z Y$c& [] Corrosives: <br /> Sweeps Number: [ ] Dusts: <br /> Proposed Date of investigatior/inspecrion: (i IU' 9L- ( ] Explosives: <br /> [ ] Flammables: <br /> 2. 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 /> [ ] Tank/Pipe Removal ( ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Sire Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: mc, v'l1. Monitoring Equipment: (note: Monitoring <br /> T instruments must be used for all operations <br /> 4. Type of Operation: vcm .,Qrejuc\\ (-,., unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( I YES "0 ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [T-N-0 ( ] 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 /> U� ill moi'ev��PrOcG-�c�c�,. Ct�«s <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply& describe) <br /> [ ] Heat or Cold Stress: °F (high ambient temp.) <br /> ]'Noise Source: 2. Personal Protective Equipment <br /> ( ] Oxygen Deficiency: Level of Protection: ( ]A [ ]B [ ]C [�H' <br /> ( ] Excavation: (falls, trips ,slipping, cave-ins) (Hard hat <br /> [a-Handling and Transfer of a Hazardous Substance: [-I-Safety glasses/goggles <br /> (fire, explosions, etc.) C-or;O�.c [a Steel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury&trauma resulting (�]- IF Baring 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 ( ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [,,yOther/Unknown (specify): PART IV <br /> PIAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health " <br /> and Safety, e.g., power lines, in of dikes, terrain, etc.): Plan Prepared by. Date: EG Z <br /> Plan Approved by: Date: � a l2'2� <br /> EH23081 (2/7/92) <br />