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0 0 <br /> SAN 1OAQUIlY COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PL..�'I <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: (�all_ , G.I lwivi, n, l 1� o/ 1. Chemicals Hazards <br /> Address: f, [gyp�d�iK2� <br /> Contact Person: Phone No. [] Corrosives: <br /> Sweeps Number. >'Rusts: <br /> Proposed Date of imesrigarion/inspecrion [ j Explosives: <br /> �� Q �Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ New UST InstallationUAR Investigation >Metals: &ez V <br /> [ ] Tank Closure in Place [] Tank/Pipe Repair [ j Oxidizers: <br /> )�'f,Tank/Pipe Removal [ ] Re-excavarion [] PCB's- <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Soecific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. 1I Tank Capacity ?V0004- 11000 EQUIPMENT <br /> Tank Contents: lc ank Age: <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> instrumenrs must be used for all operations <br /> 4. Type of Operation: _#1A t't C� <br /> y-pA S�Q�'pw unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History-. Combusrible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: .p.rvES [ ] NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ]CIES XN0 [ ] Photoionization Detector <br /> Background and description y previous investigation [] Organic Vapor Analyzer <br /> or incidence: ate. [ ] Other, specify: <br /> CLSSe SS .5� If monitoring instruments are nor used, <br /> C�9>n�eGsyuin ?Sir`&3 - rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Phys'� al Concerns: (check all that apply& describe) <br /> jjQ Ei or r Cold Stress: � ' OF (high ambient temp.) <br /> Noise Source: B it BC_ 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C )<D <br /> Escavarion: (falls, [rips ,slipping, cave-ins) Hazd hat <br /> Handling and Transfer of a Hazardous Substance: XSafe y glasses/goggles <br /> (fire, explosions, etc.) reel toed/shank shoes or boors- <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> Heavy equipmenr (physical injury& trauma resulting Hearing protection <br /> from moving equipment) 13ix ZtChDe [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> Other, specify \ A/P cartridge: <br /> f�($afery vest <br /> 7. Anticipated Biological Hazards; Two-way communicarion <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> `bd Other/Unknown (specify): PART IV <br /> ` PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Healthy <br /> SDare- <br /> Plan <br /> 6 <br /> and Safety, ., power es, inrenryo�f�(likes, terrain, etc.): Plan Prepared by: Dare: <br /> aiv✓i.(i/�a <br /> Plan Approved by. Dare: <br /> EH23081 (2/7/92) <br />