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SAN JOAQUIN CONY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> 'ART I PART 11 <br /> :,ENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> Site Name: 1. Chemicals Hazards <br /> Address: (] Carcinogens: <br /> Contact Person: Phone No. [] Corrosives: <br /> Sweeps Number: [ ] Dusts: <br /> Proposed Date of investigation/inspection: ( ] Explosives: <br /> [] Flatntnables: <br /> Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [J Metals: <br /> [ ] Tank Closure in Place ( ] Tank/Pipe Repair [ J Oxidizers: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site 1 formation: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. ank Capacity: �� EQUIPMENT <br /> Tank Contents: Tank Age: 6 y�5 <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ ] 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 /> Potential Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> [ ] Heat or Cold Stress: of (high ambient temp.) 2 Personal Protective Equipment <br /> [ ] Noise Source: <br /> [ J Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C [ ]D <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) <br /> [ I Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: C ] Steel glastoed/s glasankses/goggles <br /> or boots <br /> (fire, explosions, etc.) <br /> ( ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [ J Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ J Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> ?. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] <br /> Snakes.-Other' <br /> nakes. [ ] Insects [ ] Rodents [ ] Poisonous Plants PART IV <br /> [ ] Other/Unknown (specify): 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: Date: <br /> 12 <br />