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0 • <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: 1. Ch�micals Hazards <br /> Address: M i7 (lYCarcinogens: <br /> Contact Person:" i4±1 " Phone No.' z ,, a Scs> [] rrosives: <br /> Sweeps Number. - Z� f (9'Dusts: <br /> Proposed Date of investigation/inspection: [<QExplosives: <br /> [a Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [ ] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> W-'r'ank/Pipe Removal [ ] Re-excavation WCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: J REQUIRED PERSONAL PROTECPIVE <br /> Tank No. u Tank Capacity: ,;X. /crag 1 X)Ju EQUIPMENT <br /> Tank Contents: N.>k-o.a :: aialc Age: „e <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 /> pro)n�ded) <br /> S. Release History: [y"Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: XYES [ 6o [ ] 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 /> (YIHeat or Cold Stress: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment i <br /> [ ] pxygen Deficiency: Lev - of Protection: [ )A 1113 11C [qD <br /> [J/Excavation: (falls, trips ,slipping, cave-ins) [ Hard.hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [4`80ety glasses/goggles <br /> (fire, explosions, etc.) N'Steel toed/shank shoes or boots <br /> ( ] nfined Space entry: (explosions) [ ] e retardant coveralls <br /> [✓J Heavy equipment (physical injury& trauma resulting UYHearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ I Safety vest <br /> 7. Anticipated Bio�I cal Hazards [ ] Two-way communication <br /> [ ] Snakes []"Insects [I 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: yr, Date: <br /> Plan Approved by: PL( J Date: l <br /> EH23081 (2/7/92) <br />