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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: Vt 1. Chemicals Hazards <br /> Address: (n! 'I, [] Carcinogens: <br /> Contact Person: L hone No. [J Corrosives: <br /> Sweeps Number. [ l Dusts: <br /> Proposed Date of investigarion/inspection: [ ] Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] N UST Installation [ ] UAR Investigation [ ] Metals: <br /> [ ] 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. Specific Site Information: I REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: ( O D 6 EQUIPMENT <br /> Tank Contents: Q I PS 2� Tank Age: /C <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 ( ] 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 /> Physical Concerns: (check all that apply & describe) <br /> [ ] Heat or Cold Stress: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Lev�k of Protection: [ ]A [ ]B [ 1C [ ID <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) (T Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: ( ] SaW glasses/goggles <br /> (fire, explosions, etc.) (G]-steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ l 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 [ ] Rodents [ ] Poisonous Plants <br /> [ 1 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-.Iate: <br /> Plan Approved by./ Date: Ge <br /> EH23081 (2/7/92) <br />