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,AX JOAQL�i COUTI'I'Y r+�ROivll�lE -kL. =-kL7H DIVISION <br /> SITE HEALTH ADiD SAFr=- PLa1N <br /> o ART j PART II <br /> cmNERAL Srin agFoRM?�;-II^ON EVALUAIION OF POTS AL HAZARDS <br /> 1. Site Name: t— 1. CEe�icaLs Fazards <br /> Address: 44;Farcnogens: AfAtr=EA , <br /> Contact P_'son: Phone \L10(2& C I Corrosives: <br /> Sweeps Number: CI usE <br /> Proposed Date of invesrigarion/inspect on: FF�p losives: <br /> les: AyoF7k1- <br /> 2 Des¢iDrioa and 'brief narrative of iasnecrion ac_7i . ( I norgamc Cases: <br /> C ] New GST Installation C I UAR Iavesrigarion C I Mme= <br /> C I Tank C:osure in Place ( ] Tank/Pipe Repan C 1 Oudize_-s: <br /> Tan.VPipe Removal C I Re-excavarion C l PC3 s: <br /> [ j (nscalarion of Borsgs/Moniraring Wets <br /> ?ART III <br /> 3. SoecEc Site t_notmaeon: REQLTRED P>=TLSON?l PROTECTNE <br /> Tank Vo. l O Tank Capadry: _(b EQUIIVT <br /> Tank Col �es�l_ Tank Age: �1� tc- <br /> nt ?. Morimring =Qnipment: (note: Vor_^tor'ing <br /> Crner: <br /> =s--=enrs mLT JC used for al operations <br /> Type of Oae�rioa - = •-�- —��ar�N� unlessanDmurare adonaie ares=='ons are <br /> provided) <br /> 5. Release :srorr 'f fombusrible Gas/Oxygen Mete: <br /> vc- Detector Tubes (Sbecify) <br /> c�ride^ca of leaks/sal coa+}r+i*+ador.: C ] � C w0 C 1 <br /> Doc rne^_red Groundwater cpntamin"n: C I 5 �O ( : Photpia 'an De ecmr <br /> Background and des(=prion of any Previous avesdgadotc (I Or anic Vapor Praiy= <br /> ar ncde^ce: [ 1 Oche rpecsy <br /> If apnimring ai�se^ts are not sed <br /> =40rale or acsvirf/area res'-c--o=: <br /> 5. Potential. -eaith and Safe-7 <br /> Physics! Conce^-s: (check al that apniy& desebe) <br /> ( ] -eat or Cold Stress: of Cniga ambient n=p.) <br /> �].:Voise Source: s�w',�Qw 11— - 2 Personal Proceave cauipment <br /> C ] Oxygen Dedciene/ Leve! of Proreapn: (lA C IB C IC k V <br /> (,] Z Cavanon: (falls, SDs ,sLippmg, cave-!ns) [ ;3rd alar <br /> C ] Handand Transfer of a razardous Subs�anc ;CI Safe_ry asses/gog�es <br /> Siz <br /> (Ere, e=iosions, etc) _r toed/shaak shoes or boors <br /> dame retardant coverals <br /> [ ] Gonraed Space antry (explosions) Pa :ng protecripa <br /> G Feavy e='Dmenr (Paysic i sjury 3c =Uma resulting ,kl- <br /> som moving equipment) ( 1 Tyvek <br /> C ] Respiraror, ace: APR or SC3A <br /> C I Other. specry Alt) car=dge.- <br /> [ j Safety vest <br /> 7. Anridpated 3i0109cl Fz=ds: [ 1 Two-way catmm�nicrioe <br /> C l Snakes *Insecs NV.Rodents [ 1 Poisonous Plants <br /> C 1 Other/Unleaown (specify): PART N <br /> PLaN APPROVAL <br /> 8. Narmdve (provide all nfprmarion winch could impar health <br /> and Safe_y, z.g., Power lines, inregtr/or dices, cera uem ?Ian Prepared Sy C t Care <br /> Plan Approved b): _ Date. <br /> ai2308I (2/7/92) <br />