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SAN JOAQUIN COUNTY ENVIRONMENTAL 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: ����ESi -7- <br /> 1. Chemicals Hazards <br /> Address: lin '2r ✓kn7o,'�_ 96> [] Carcinogens: <br /> so <br /> Contact Pern:,8a�W-2i/..w4,t!r Phone No. g—Ztr7Z [J Corrosives: <br /> Sweeps Number. __/7 ] [ ] Dusts: <br /> Proposed Date of investigation/inspection: U- K, 4�1 Explosives: <br /> IQ Flammables: <br /> 2. Description and brief narrative of inspection activity. [ J Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation `MMetals• <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ J Oxidizers: <br /> 1°]-Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Infprmation: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. G{� Tank Capacity: /ro.a EQUIPMENT <br /> Tank Contents: w/o Tank Age: <br /> Other. 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: rya_, Ir(tl�- j—itlafi/ unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History, Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES NO [ I Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES NO [ J Photoionization Detector <br /> Background and description of any previous investiga on [] Organic Vapor Analyzer <br /> or incidence: [ J 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 /> -r] Heat or Cold Stress: of (high ambient temp.) <br /> Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [7]C %k]D <br /> R Excavation: (falls, trips ,slipping, cave-ins) Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) k Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> ] Heavy equipment (physical injury& trauma resulting ¢(] Hearing protection <br /> from moving equipment) ] Tyvek <br /> [ [ Respirator, circle: R_or SCBA <br /> [ I Other, specify A/P cartridge: <br /> [] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ J Poisonous Plants <br /> [ I 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: <br /> i ,1�> Date: �/ •--! <br /> EH23081 (2/7/92) <br />