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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALiT-I DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> s <br /> 1. Site Name: y 1. Chemicals Hazards <br /> Address: []""Carcinogens: <br /> Contact Person: ne No. []Corrosives: <br /> Sweeps Number. Dusts: <br /> Proposed Date of investigation/inspection: [ ] 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 Borins/Monitorin Wells <br /> GUsEfi/3 TC .Z'l USCnU� PART III <br /> 3. Spec c Site Information: C9• REQUIRED PERSONAL PROTECTIVE <br /> Tank No. ank Capacity: EQUIPMENT <br /> Tank Conten e• <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 /> 5. 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 descri tion 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.) 0. { <br /> oise Source: 'W Q /.� 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B jC- )�D <br /> ( j Excavation: (falls, trips ,slipping, cave-ins) Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, etc.) •Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> Meavy equipment (physical injury& traumA resulting I-fBearing protection <br /> from moving equipment) [ j Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> ,Other, specify A/P cartridge: <br /> 1� 0 KSafety vest <br /> 7. Anticipated Biological Hazards: 4 [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> ( ] Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL !"• .�,C/7 <br /> and Safety, e.g., power lines, inte ' of dikes, terrain, etc.): Plan Prepared by:/ Date r <br /> Plan Approved by Dai 7 <br /> EH23081 (2/7/92) <br />