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SAM JOAQUIN COUNTY E1�VIIZONMEN'IAL IALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAIN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: d- 1._ �A G�r �<C.'t_- 1. Chemicals Hazards <br /> Address: &\`\`'-:, T_\ My ( arcinogers: <br /> Contact Person: ._ F= s� Phone No. (1 Corrosives: <br /> Sweeps Number. GT'Dusts: <br /> P-oposed Date of investganon/inspection: [ I --plosives: <br /> (� rlammables• <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation ( ] Merals• <br /> [ ] Tank Closure in Place ( ] Tank/Pipe Repair [ 1 Oxidizers: <br /> Cej-tank/Pipe Removal [ I Re-excavation [1 PCB's: <br /> ( ] Installation of Borings/Monitoring Wets <br /> PART 1H <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. -t:, Tank Capacity: 2,00(D EQUIPMENT <br /> Tank Contents: UL Tank Age: ly�r, <br /> Other 1. Monitoring Equipment: (note: Monitoring <br /> ins-uments must be used for all operations <br /> 4. Type of Operation: `�c4' �- S 0.f(O+l unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release Fdstor-y (,-rCombusrible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ I YES IkIN0 [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ I YES [ANO [ ] Photoionizarion Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ I Other, specuy. <br /> If Wonitoring int=ents are not used, <br /> rationale or activity/area restrictions: <br /> 6. Pocenrial Health and Safety <br /> physical Concerns: (check ail that apply & describe) <br /> [y Heat or Cold Stress: °F (high ambient temp.) <br /> [kl Noise Source: 2. Personal Protective Equipment <br /> [ I Oxygen Deficiency: Lev 1 of Protection: [ JA ( IB [ 1C G� <br /> [k]'Lxcavarion: (falls, trips ,slipping, cave-ins) (,lard hat ` <br /> [ ] Handling and Transfer of a Hazardous Substance: [v Slry glasses/goggles <br /> (fire, explosions, etc.) [/�Steei coed/shank shoes or boots <br /> [ ] ;onnned Space entry: (explosions) [ ] Flame retardant coveralls <br /> [,i]'Heavy equipment (physical injury& trauma resulting [ I Hearing protection <br /> from moving equipment) [ I Tyve-k <br /> [ ] Respirator, circle: APR or SC3A <br /> [ ] Other, specify A/P car=.dge: <br /> [ ] Safety vest <br /> 7. Anticipated 3iologiza <br /> cal Hards: ( ] Two-way communication <br /> [ ] Snakes [ I Insects [ ] Rodents ( ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PRT IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, ce_*rain, etc.): Plan Prepared by: })T Date: S <br /> Plan Approved by- Date: c — <br /> E:-23081 (2/7/92) <br />