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SAN JOAQ= COUTITY E2�'LRONME:I1TA HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PL_ N <br /> PART I PART II <br /> GaNERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: N11 C;, C fi I. Chemicals Hazards <br /> n <br /> Address: S ( ( S �., lel ��iaY; C`(c; ? Carcinageys: <br /> Contact Person: Phone No. [J Corrosives: <br /> Sweeps Number: [']'Dusrs• <br /> Proposed Date of investigadon/inspection: _ [ ] =1osives: <br /> rlammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> ( ] New UST Installation [ ] UAR Investigation [ J Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair ( ] Oxidizers: <br /> [ ] Tank/Pipe Removal [ J Re-excavation []?CB's: <br /> ( ] Installation of Borings/Monitoring Wells <br /> ?ART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank ank Capacity: EQUIPMENT <br /> Tank Conrenrs: C-J- Tank Age: <br /> Other: 1. Moniroring Equipment: (note: Monitoring <br /> cc '' ===mems must be used for all operations <br /> 4. Type of Operation: Ll� unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History Cj�&mbustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ I YES [X10 [ ] Detector Tubes (Specify) <br /> Docamented Groundwater contamination: ( ] YES �_�O ( ] ?hotoionization De'sector <br /> 3ackground and description of any previous investigation [J Crganic Vapor Analyzer <br /> or incidence: [ ] Other, specify: <br /> If Wonitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Pocenrial Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> G� at or Cold Stress: of (high ambient temp.) <br /> ( Noise Source: 2. Personal Protective -Equipment <br /> [ I Oxygen Deficiency Level of Protection: [ JA [ JB [ IC [klls <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) [/�Hard liar ` <br /> Handling and Transfe- of a Hazardous Substance: C,,ySafery glasses/-o <br /> (fire, explosions, etc.) �teei coed/shank shoes or boors <br /> [ ] Confined Space entry: (explosions) ( I Flame retardant coveralls <br /> VI-Peavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] Tyve-k <br /> [ I Respiraror, circle: APR or SC3A <br /> [ ] Other, specify A/D cartridge: <br /> [ I Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes ( ] Insects [ ] Rodents [ ] Poisonous Plants <br /> ( ] <br /> Other/Unknown (specify): P?.RT N <br /> PLAN APPROVAL <br /> S. Nairative (provide ail information which could impact Health �� <br /> and <br /> d1-Safety, e.g., Dower lines, integntyty of dikes,I terrain, etc.): ?!an Prepared by: Date: 7 - <br /> —4.: 1 c 1 ���L _�:L�o c� _ c t c� Plan Approved by-. Date: <br /> F_ 23081 (2/7/92) <br />