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rnNFUNTIAL <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORIMATION EVALUATION OF POTENTIAL HAZARDS <br />Site Name: COLI 16vr eta- t�cLtl . 6tooa- <br />Address: 6 �r a <br />Contact Person'AAm4—�..�,aJ� Phone a e 3 • S4 <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ ] Tank/Pipe Removal [ ] Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />T � <br />3.`Specific Site Information: <br />Tank No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Other: <br />4. Type of Operation: M0PubR-Ma40K Ck. SK4 P <br />Release History: <br />Evidence of leaks/soil contamination: [ ] YES []NO <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />Background and description of any previous investigation <br />or incidence: <br />Chemica Hazards <br />Carcinogens: <br />Corrosives: <br />] Dusts: <br />[ ] Explosives: <br />ZFlammables: <br />[ ] organic Gases: <br />[>Metals: <br />[ ] Oxidizers: <br />[ ] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIP`IENT <br />Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />[ ] Combustible Gas/ Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ ] Organic Vapor Analyzer <br />[ ] 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: °F (high ambient temp.) <br />(�loise Source: <br />2. Personal Protective Equipment <br />Level of Protection: [ ]A [ ]B [/j'6 <br />[ ]C <br />[ ] Oxygen Deficiency: <br />[ Hard hat <br />[ ] Excavation: (falls, trips ,slipping, cave-ins) <br />[/� Safetyglasses/gogglesnkshoes <br />Handling and Transfer of a Hazardous Substance: <br />�] Steel toed/shank s or boots <br />(fire, explosions, etc.) <br />[ ]Flame retardant coveralls <br />[ ]Confined Space entry: (explosions) <br />[Heavy equipment (physical injury & trauma resulting <br />[Hearin g protection <br />from moving equipment) <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] Other, specify <br />A/P cartridge: <br />[Safety vest <br />7. Anticipated Biological Hazards: <br />[ ] Two-way communication <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />PART IV <br />[ ] Other/Unknown (specify): <br />PLAN; APPROVAL <br />8. Narrative (provide all information which could impact Health <br />Plan Prepared by: Q�d rl2l Date: <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Approved by. Date: <br />EH23081 (2/7/92) <br />