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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, i/ic,-� C'-%' S 1. Chemicals Hazards <br /> Address: iy i F. ;,e r 5't - [] Carcinogens: <br /> Contact Person: rvrti 6/0 / Phone No. ,,'4j 9- 5,3 [] Corrosives: <br /> Sweeps Number: //b3 [ ] D <br /> Proposed Date of investigation/inspection: olives: <br /> [ Flammables- <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New IJST Installation ( ] UAR Investigation [] Metals: <br /> [ ]3afik Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> Tank/Pipe Removal [ ] Re-excavation <br /> []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRM PERSONAL PROTECMIE <br /> Tank No. 2 r o.,o,o i Tank Capacity: 100 0000 �� EQUIPMENT <br /> Tank Contents: �o « Tank Age: cc�— <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: pro <br /> ppropriate rationale or restrictions are <br /> pro ed) <br /> 5. Release History: [ Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] NO [ ] 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: S „/ h� ,.�G ," !< « v [ ] Other, specify: <br /> C '14Z fz, 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 /> Wtlegt'or Cold Stress: of (high ambient temp.) <br /> [ Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Lev of Protection: ( ]A [ ]B [ ]C [ ]D <br /> Lq]' xcavation: (falls, trips ,slipping, cave-ins) (T�Iard hat <br /> [4 Handling and Transfer of a Hazardous Substance: j <br /> (fire, explosions, etc.) [ el glasses/goggles <br /> [ nfined Space entry: (explosions) [ Steel toed/shank ank shoes is boots <br /> [ Heavy equipment (physical injury& trauma resulting ( ] Flame retardant coveralls <br /> ( ] Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> Other, specify a A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] 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: s� <br /> U ex n/OS i n <br /> /-0 Approved by: C)60 Date:L-Pr3 <br /> EH23081 (2/7/92) �� st %�{o piosSw izi of h lC� <br />