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0 0 1 <br /> SAN JOAQUIN COUNTY EINVIRONMEI�]TAL HEALTH DIVISION <br /> S= HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: [J Carcinogens- <br /> Contact Person: Phone No. []Corrosives: <br /> Sweeps Number. [ ] Dusts- <br /> Proposed Date of investigadon/inspecrion: [ ] Explosives: <br /> [] 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 /> [ ] Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Soecific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <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 /> provided) <br /> S. Release History: ( ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( ] NO [ ] Phoccionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ ] Other, specify: <br /> If monitoring instruments are nor used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply& describe) <br /> ( ] Hear or Cold Stress: of (high ambient temp.) <br /> [ ] Noise Source: 2 Personal Protective Equipment <br /> ( ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C ( ]D <br /> ( ] Excavation: (falls, trips ,slipping cave-ins) ( ] Lard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, erc.) [ ] Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) ( ] Flame retardant coveralls <br /> [ ] Heavy equipmenr (physical injury& trauma resulting ( ] Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> ( ] Respirator, circle: APR or SC3A <br /> [ ] Other, specify A/P cartridge: <br /> ( ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects ( ] Rodents [ ] Poisonous Plans <br /> [ ] Orher/Unknown (specify): PARTIV <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:Ste_ Date: <br /> Plan Approved by. Dare: <br /> EH23081 (2/7/92) <br />