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SAN JOAQUIN COUN'T'Y 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: ( yj/y/�y/ci��i/�LjnJ /�1D�c? f� 1. Chemicals Hazards <br /> Address: 42,e�%/ F, � Syj c�{�, [] Carcinogens: <br /> Contact Person: Phone No. [] Corrosives: <br /> Sweeps Number. 1 j) L� '7 y �usts: <br /> Proposed Date of investigation/inspection: / [ lFllosives: <br /> ammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> ( j Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> ><Tank/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. Tank Capacity: 7 56 p ,;L EQUIPMENT <br /> Tank Contents. Tank Age: v 5",04ea4.j <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ..�dd-�� instruments must be used for all operations <br /> 4. Type of Operation: ��iyl1 ('; ho� unless appropriate rationale or restrictions are <br /> provided) <br /> 5. 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 descrippdan of any previous investigation [j Organic Vapor Analyzer <br /> or incidence: GGy a!J n. 3 c �1 z� 9 I 1 <br /> f fl f] �i,1t� [ ] 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: _jL.(LOF (high ambient temp.) <br /> [ ] Noise Source: ,h k A-e—C , 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: ( ]A [ ]B [ ]C XD <br /> Excavation: (falls, trips ,slipping, cave-ins) >4�-iard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> Heavy equipment (physical injury& trauma resulting Hearing protection <br /> from moving equipment) A Tyvek <br /> ( ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> Safety vest <br /> 7. Anticipated Biological Hazards: &/O N F_ [ ] Two-way communication <br /> ( ] Snakes [ ] Insects ( ] Rodents [ ] Poisonous Plants <br /> ( ] Other/Unknown (specify): PART IV <br /> PIAN 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 /> T cLyt(%'cJ 7 St/V SLC/ �. <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />