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SAN JOAQUIN CGUIN Y ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL.SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> r <br /> 1. Site Name: c 1. Che s Hazards <br /> Address: 3 JS :1ST- in ens: <br /> Contact Person: .�_y_h_y)_[ ���.s� Phone No. '[V yas-Sb v6 ( os'ves: <br /> Sweeps Number. /c75-0 [ Jill <br /> Proposed Date of investigation/inspection: [' losives: <br /> Flammables• <br /> 2. Description and brief narrative of inspec:.on activity: [ j Inorganic Gases: <br /> ( ] New ST Installation [ ] UAR Investigation (] Metals: <br /> L l Closure in Place [ ] Tank/Pipe Repair [] Oxidizers: <br /> E ank/Pipe Removal ( ] Re-c=vation (] PCB's: <br /> L I Installation of Borings/Monitoring Weds <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. ^v so--off Tank Capacity: /v 0 v EQUIPMENT <br /> Tank Contents: /tea d G.,Q Tari Age: L4C_ <br /> Other: l.`.Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: G 5 S =-, unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release Historf. WCombustible Gas/Oxygen Meter <br /> Evidence of leaks/sod contamination: [I YES [qNO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contaminations (] YES L ] NO [ J Photoionization Detector <br /> Background and description 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 /> b. Potential Health and Safety <br /> Physical oncerns: (check all that apply&describe) <br /> { ] Hardt o-Cold Stress: OF (high ambient temp.) <br /> o' Source: 2 Personal Protective Equipment <br /> [ J en Deficiency. Level rection: [ ]A [ ]B []C [ ]D <br /> { Excavation: (falls, trips ,slipping; cave-ins) [' hat <br /> Zeavyand Transfer of a Hazardous Substance: ( ery glasses/goggles <br /> osions, etc.) { Ste ed/shank shoes or boots <br /> Space entry. (explosions) [ ] e retardant coveralls <br /> uipment (physical injury&rauma resulting Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> ( ] Respirator. circle: APR or SCBA <br /> ( ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> { ] Snakes [ ] Insects [ I Rodents {] Poisonous Plants <br /> [ ] Other/Unkaown (specify): PART N <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information whicz could impact Health f J /3�y <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: ate: <br /> Plan Approved by: _ Aar Dat4*v <br /> E.u.23081 (2/7/92) '`T <br /> l <br />