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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL.SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: l4,– 'rld/tab7r'1 /`(14444A-VkL° 1. Chemicals Hazards <br /> Address: e7.�, ) 4�7 Carcinogens: <br /> Contact Person: Phone No. G [] Corrosives: <br /> Sweeps Number: "Z–h ( ] Dusts: <br /> Proposed Date of investigation/inspection: (4-fixplosives: <br /> {'fFlammables: <br /> 2. Description and brief narrative of inspection activity: ( ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [;I,Metals: <br /> [ ] <br /> Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> [ ank/Pipe Removal [ ] Re-excavation [J PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. I Tank Capacity: "t EQUIPMENT <br /> P tY� ` <br /> Tank Contents: O 4;6v`lt' Tank Aje. <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 /> 5. Release History: L] (fombustible 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 /> 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 /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ JC ( ]D <br /> (4—cavation: (falls, trips ,slipping, cave-ins) (r Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ Y$afety glasses/goggles <br /> (fire, explosions, etc.) ['T'Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> I ]'Heavy equipment (physical injury & trauma resulting Ef Hearing protection <br /> from moving equipment) [.Jtyvek <br /> [-]'Respirator, circle: `M_ or .SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes ( ] Insects [ ] Rodents ( ] Poisonous Plants <br /> ( ] 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: L Date: <br /> Plan Approved by: tic Date. <br /> EH23081 (2/7/92) <br />