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SAN JOAQUIN Cou•Y ENVIRONMENTAL HEALTH�]VISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART II <br />`ART I EVALUATION OF POTENTIAL HAZARDS <br /> -NERAL SITE INFORMATION <br /> r 1. Ch icals Hazards <br /> Site Name: [ cinogens: J /1 <br /> Address: r6 z O rrosives: <br /> Contact Person:lbl. f/nSa�s¢�PZ_ Phone ao d 3 5af`f �]_yr° cin• <br /> �rII u: <br /> Sweeps Number: I _wQ _ �— Ic 9 (y plosives: <br /> Proposed Date of investigation/inspection: SL511JJ—� Flammables: le <br /> ] organic Gases: <br /> Description and brief narrative of inspection activity ,T Metals: <br /> New UST Installation [ J UAR Investigation [ <br /> Tank/Pi a Repair [ ] Oxidizers: <br /> ( ]Tank Closure in Place I ] P P [] PCB's: <br /> )KTank/Pipe Removal [ ] Re-excavation <br /> [ ] Installation of Borings/Monitoring Wells PART III <br /> Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. <br /> (9(t3— { Tank Capacity: ��DeJ D EQUIPMENC <br /> Tank Content I Tank Age: �� V <br /> 1. Monitoring Equipment: (note: Monitoring <br /> Other: instruments must be used for all operations <br /> Rig a/e` / p� unless appropriate rationale or restrictions are <br /> t. Type of Operation: — pro . d) <br /> [ Combustible Gas/Oxygen Meter <br /> 5. Release History: ( ] Detector Tubes (Specify)_ <br /> Evidence of leaks/soil contamination: I ] YES >" No ( ] photoioniza[ion Detector <br /> Documented Groundwater contamination: [ ] YES 1"�- organic iz tion Deor tector <br /> Background and description of any previous investigation zer <br /> Other, specify: <br /> or incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 5. Potential Health and Safety <br /> Ph ical Concerns: (check all that apply & describe) <br /> [ of (high ambient temp.) <br /> or Cold Stress: /nos 8 2. Personal Protective Equipment <br /> [ Noise Source- /a j.,ts_e <br /> Lev of Protection: [ ]A [ JB [ ]C [ ]D <br /> [ ] gen Deficiency: [ rd hat <br /> xcavation: (falls, trips ,slipping, cave-ins) [ Ary glasses/goggles <br /> [ ] Handling and Transfer of a Hazardous Substance: ( steel toed/shank shoes or boots <br /> (fire, explosions, etc.) [ ] Flame retardant coveralls <br /> ( ] nfined Space entry: (explosions) Hearin protection <br /> [tj/Heavy equipment (physical injury& trauma resulting Tyiek g P <br /> from moving equipment) ( ] Respirator, circle: APR or SCBA <br /> cartridge: <br /> ( ] Other, specify ft4afery vest <br /> [ ] Two-way communication <br /> 7. Anticipated Biological Hazards: N R' . <br /> ( ] Snakes;- [ ] Insects [ ] Rodents [ ] Poisonous Plants PART IV <br /> [ ] Other/Unknown (specify): PLAN APPROVAL q <br /> 8. Narrative (provide all information which could impact Health plan Pre ared b}K� ML Dale: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): P <br /> Plan Approved 6'y: Q _ Date: _ <br /> D/J <br /> 12 <br />