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4 a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: -Il(v Tl.'-�e o / 1. C,h�icals Hazards <br /> Address: 7E, ��,„ L . k �n, G? [ptati ' ogens: <br /> Contact Person: Geo u /ue« hone No. j. i i'ii [ osives: <br /> Sweeps Number: i/ .1- (i] Dusts: <br /> Proposed Date of investigation inspection: [ losives: <br /> [� <br /> flair <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New ST Installation [ ] UAR Investigation [] Metals: <br /> [ ] T Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> [�yTank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. i/za 0/ Tank Capacity: i L�, or��Jy�� EQUIPMENT <br /> Tank Contents: /o ,c c - Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless.apropriate rationale or restrictions are <br /> pro ) <br /> 5. Release History. ' [ ombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( ] YES ENQ- [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES (j 0 [ ] 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. Poten�6] Health and Safety <br /> Physic Concerns: (check all that apply& describe) <br /> [ at or Cold Stress: °F (high ambient temp.) <br /> [J/Noise.-Source: 2. Personal Protective Equipment <br /> [ ] 94;ien Deficiency: Level of Protection: CIA [ ]B ( ]C [ ID <br /> H Excavation: (falls, trips ,slipping, cave-ins) ( ] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: C Safety glasses/goggles <br /> (fir ,, explosions, etc.) ( ] Steel toed/shank shoes or boots <br /> [ ]f¢"onfined Space entry: (explosions) [ ] Flame retardant coveralls <br /> VHeavy equipment (physical injury & trauma resulting [ 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 /> [ ] Snakes [ ] Insects ( ] Rodents [ ] Poisonous Plants <br /> ( ] Other/Unknown (specify): r=- - i— 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- r Date: �l / <br /> Plan Approved by- I Date: Lk�' 3 <br /> EH23081 (2/7/92) <br />