Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONN EN I'AL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />PART U <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: T s4 <br />Address: caw// vii rta� n? p oa/ <br />Contact Person:y3,pa Phone No. 5 <br />Sweeps Number: /7c/ <br />Proposed Date of investigation/inspection: 4, <br />2. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />( ] Tank Closure in Place [ ] Tank/Pipe Repair <br />h—Tank/Pipe Removal [ ] Re -excavation <br />(I Installation of Borings/Monitoring Wells <br />Chemicals Hazards <br />"MCarcinogens: <br />[] Corrosives: _ <br />[ ] Dusts: <br />'¢j. Explosives: <br />�lammables _ <br />[ ] Inorganic Gases: <br />[ ] Metals: <br />[ ] Oxidizers- _ <br />[ ] PCB's: <br />3. Specific Site Information: <br />Tank No. /, Z W-3 Tank Capacity: ink iZX <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />-Sk <br />Tank Contents: 4dV ,4kSjJank Age: , IL4, <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />4. Type of Operation:—y��G�i y-�� <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />S. Release History: <br />provided) <br />Evidence of leaks/soil contamination: (I YES (I NO <br />Combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />[ ] Photoionization Detector <br />Background and description of any previous investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: <br />[ ] Other, specify: <br />P ft <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: °F (highambient temp.) <br />"-Noise Source: __i771F 2,-4 <br />[ ] Oxygen Deficiency: <br />2. Personal Protective Equipment <br />1`�(falls, trips slipping, cave-ins) <br />Level of Protection: [ ]A [ ]B <br />;<cExcavation: <br />and hat <br />[ ] Handling and Transfer of a Hazardous Substance: <br />Safety glasses/goggles <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />VSteel toed/shank shoes or boots <br />Heavy equipment (physical injury & trauma resulting <br />[ ] Flame retardant coveralls <br />from moving equipment) <br />[Hearing protection <br />�Tyvek <br />[ ]Other, specify <br />'f Respirator, circle: PR or SCBA <br />A/P cartridge:_�gfy — <br />7. Anticipated Biological Hazards: <br />[ ] Safety vest <br />[ ] Two-way communication <br />[ ] Snakes [ ] Insects [ ] RodentsPoisonous Planes <br />[ ] <br />[ ] Other/Unknown (specify): <br />PART IV <br />B. Narrative (provide all information which could impact Health <br />PLAN APPROVAL <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc): <br />Plan Prepared by: ET Date: rr/ <br />Plan Approved by: l_! Date: LL-fr <br />EH23081 (2/7/92) <br />