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SAIN JOAQUIN COUNTY ENVIRONMENTALHEALTH DMSION <br /> SITE HEALTH A,-,TD SAFETY PLAN <br /> PART II <br /> PART I I E EVALUATION OF POTENTIAL HAZARDS <br /> II�ORMATION <br /> GENERAL S <br /> 1, PDUS;1s' <br /> Hazards <br /> L Site `lame: N L ens: <br /> Address: n� " ' S�y��Lf� [ es: <br /> Contact Person: oh =� Phone No.� Y'- 5d 3 3��I ( <br /> Sweeps Number: ." -2 [ ] osives: <br /> Proposed Date of investigation/inspection: �— [ ables: <br /> Inorganic Gases: <br /> 2. De pnon and brief narrative of inspection activity: [] Metals: <br /> :'� <br /> Installure ination [ ] UAR Investigation [] Oxidizer: <br /> Tank/? <br /> IPe Repair []PCB s: <br /> ] T o a RemovalCeRe•excavadonap <br /> [ ] Installation of Borings/Monitoring Wells PART III <br /> REQUQtED PERSONAL PROTEC VE <br /> 3. Specific Site Information: EQUIPMENT <br /> Tank No r iMonitoring <br /> —n(ry Tank Capacity: O O <br /> e 1. Monitoring Equipment (note: <br /> TankContents: iirz�'"��2�' Tank instruments must be used for all operations <br /> Other: <br /> unless ap apriate rationale or restrictions are <br /> a. Type of Operation: i sup <<z °m pro <br /> ' d) <br /> [ Combustible Gas/Oxygen Meter <br /> S. Release History. / [ ] NO [] Detector Tubes (Specify)-- <br /> Evidence of leaks/soil contamination: [ �, [ ] photoionization Detector�— <br /> Documented Groundwater contamination: [] YES [ ] NO (] Organic Vapor Analyzer <br /> Baclground and description of any previous inves�aao� [ ] Other, specify. <br /> or incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety & describe) <br /> Physical hcerns: (check all thaapply& ambient temp) <br /> [ J <br /> aatt or Cold Stress: y Personal Protective Equipment <br /> [ No Source: Level rotection: [ ]A I1 [ lC [ 1D <br /> [ ] gen Deficiency: (qd h t <br /> Excavation: (falls, trips ,slipping, cave-ins) [ S glasses/goggles <br /> [ ] Handling and Transfer of a Hazardous Substance: [ reel <br /> to <br /> shoes or boots <br /> (fire Iosions, etc.) losions) ( ] Flame retardant coveralls <br /> [ ] ed Space entry: CSP _ [ ] Hearing protection <br /> [Lf Heavy equipment (physical injury&trauma resulting [ ] ,eek <br /> from moving equipment) [ ] Respirator, circle: APR or SCBA <br /> Alp cartridge: <br /> [ ] Other, specify [] Safety vest <br /> ( ] Two-way communication <br /> 7. Anticipated Biological Hazards:dents [] Poisonous Plants <br /> [ ] Snakes [ ] Insects ( l PART IV <br /> ( ] <br /> other/Unknown (specify): PLAN APPROVAL <br /> 8. Narrative (Provide all information which could impact Health Prepared b Date: ,yA9� <br /> gri of dikes terrain, etc.): Plan Prep Y• <br /> and Safety, e.g., power lines, integrity <br /> Plan Approved by: _ Date: <br /> E. 3081 (2✓7/92) <br />