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SAN JOAQUIN COUCJTY ENVIRONMENTAL HEALThODIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> 'ART I PART II <br /> ZNERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> Site Name: 1. Chicals Hazards <br /> Address: Carcinogens: <br /> Contac[Person: Phone N (] Corr lives: <br /> Sweeps Number. <br /> Proposed Date of investigation/inspection: �Cn^ [Fliannimables:ives: <br /> [ <br /> Description and brief narrative of inspection activity: [ ] Igqorganic Gases: <br /> [ I New UST Installation ( ] UAR Investigation [I-Metals: <br /> ( ] jdnk Closure in Place ( ] Tank/Pipe Repair [j Oxidizers: <br /> [. ank/Pipe Removal [ ] Re-excavation <br /> []PCB's: <br /> ( ] Installation of Borings/Monitoring Wells <br /> PART III <br /> Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. 02- Tank Capacity: 2000 G A'f EQUIPMENT <br /> Tank Contents: Tank Age: _ ti 756 yS <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> /�M instruments must be used for all operations <br /> i. Type of Operation: /�-� unles ppropriate rationale or restrictions are <br /> pro Zed) <br /> 5. Release History: [ Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ,YES [ ] NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: I YES [ I NO [ J Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: I I Other, specify: <br /> P fY: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 5. Poten al Health and Safety <br /> Phy cal Concerns: (check all that apply & describe) <br /> Heat or Cold Stress: of (high ambient temp.) <br /> [ ] <br /> No a Source: 2. Personal Protective Equipment <br /> [ ] gen Deficiency: Lev l of Protection: ( ]A ( ]B ( ]C ( D <br /> ( cavadon: (falls, trips ,slipping, cave-ins) [ and hat <br /> [ ] andling and Transfer of a Hazardous Substance: [ Eery glasses/goggles <br /> (fire, explosions, etc.) ( Steel toed/shank shoes or boots <br /> [ j gerifined Space entry: (explosions) <br /> [ I Flame retardant coveralls <br /> U'Reavy equipment (physical injury & trauma resulting [ j Hearing 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 /> [ ) <br /> Snakes,- ( ] Insects ( ) Rodents ( ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART N <br /> 8. Narrative (provide all information which could impact Health; PIAN APPROVAL <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: J= Date: v /� 9/ <br /> Plan Approved by:Z Date: <br /> 12 <br />