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SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION <br /> SITE HEALTH AND <br /> PART I PART 11 <br /> GENERAL SITE INFORMATION SA �' `� '�� ] <br /> EVALUATION OF POTENTIAL HAZARDS <br /> 1. Chemicals Hazards <br /> 1. Site Name: [I Carcinogens: <br /> Address: [] Corrosives: <br /> Contact Person: Phone N°' <br /> '[ ] Dusts: <br /> Sweeps Number: [ ] Explosives: <br /> Proposed Date of investigation/inspection: (] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> UAR Investigation [ ] Metals: <br /> [ <br /> New UST Installation [ l g Oxidizers: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] <br /> [ ] Tank/Pipe Removal [ ] <br /> Re-excavation [] PCB's: <br /> Installation of Borings/Monitoring Wells PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTEC'T'IVE <br /> � <br /> Tank No. Tank Capacity: EQUIPMENT <br /> -- C <br /> Tank Contents: _(T, 7Tank Age: LL4L CI- Ss�� <br /> 1. Monitoring Equipment: (note: Monitoring <br /> Other: N instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> 4. Type of Operation: ' provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> NO[ ] [ ] Detector Tubes (Specify) <br /> Evidence of leaks/soil contamination: ( ] YES ionizatian Detector <br /> organic z <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ ] <br /> Background and description of any previous investigation {] g Por Analyzer <br /> [ ] Other, specify: <br /> or incidence: 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: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> Level of Protection: ( ]A [ ]B [ ]C ( ]D <br /> [ ] Oxygen Deficiency: ( ] Hard hat <br /> [ J Excavation: (falls, trips ,slipping, cave-ins) [ ] Safety, glasses/goggles <br /> [ ] Handling and Transfer of a Hazardous Substance: ( ] Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) <br /> [ ] Flame retardant coveralls <br /> [ ] Confined Space entry: (explosions) ng protection <br /> [ ] Heavy equipment (physical injury & trauma resulting Heari <br /> Heari <br /> from moving equipment) Tyvek( ] Respirator, circle: APR or SCBA <br /> [ J A/P cartridge: <br /> Other, specify <br /> [ ] Safety vest <br /> Two-way communication <br /> 7. Anticipated Biological Hazards: <br /> [ ] <br /> [ ] Snakes; [ ] Insects [ ] Rodents [ ] poisonous Plants <br /> PART IV <br /> [ ] Other/Unknown (specify): PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health Date: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: . <br /> Plan Approved by" <br /> yDate: <br /> 12 <br />