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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chepicals Hazards <br /> Address: [ arcinogens: <br /> Contact Person: a l-F Nic-4glone No. 9'(`f- Ba7 7 [] Corrosives: <br /> Sweeps Number. [ ID su- <br /> Proposed Date of m estigatl�n "inspection: [�j F� olives: <br /> [ Flammables: <br /> 2. Description and brief narrative of inspection activity: [ l Inorganic Gases: <br /> [ ] New U T Installation [ ] UAR Investigation [ ] Metals: <br /> [ ] Torrk Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> Tank/Pipe Removal [ ] Re-excavation [I PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: SSZ j,o,�-c EQUIPMENT <br /> Tank Contents: Tank Age: u & --- <br /> Other: e ✓l d'�w 1. Monitoring Equipment: (note: Monitoring <br /> _T instruments must be used for all operations <br /> 4. Type of Operation: C c c unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( I YES [a q [ ] 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 /> Ph al Concerns: (check all that apply& describe) <br /> ['j�at or Cold Stress: of (high ambient temp.) <br /> [ Noise Source: 2. Personal Protective Equipment <br /> [�tygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C [ ]D <br /> [ Excavation: (falls, trips ,slipping, cave-ins) [ ] Hard hat <br /> [4]Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (file explosions, etc.) [ ] Steel toed/shank shoes or boots <br /> [-YCoqfmed Space entry: (explosions) [ ] Flame retardant coveralls <br /> [ eavy 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 [ I Rodents [ I 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: (�ate: 6�y3 <br /> Plan Approved by: �( � 'Date: <br /> EH23081 (2/7/92) U-) p w <br />