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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> kRT I PART II <br />:,NERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I <br /> Sice Name: ( L �X 1. Chemicals Hazards <br /> Address: tnn0a — (] Carcinogens: <br /> Contact Person: LP2n J JQ9 Phone No. Cj 5 /5.S [] Corrosives: <br /> Sweeps Number: I Dq 9 Dusts: <br /> Proposed Date of investigation/inspection: ,GHEE [ ] Explosives: <br /> [J FIammables: <br /> Description and brief narrative of inspection activity: [ J Inorganic Gases: <br /> [ ] Ne UST Installation ( J UAR Investigation `,1 [ ] Metals: <br /> [ J nk CIosure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> ( ank/Pipe Removal [ ] Re-excavation [] PCB's: <br /> [ J Installation of Borings/Monitoring Wells <br /> PART III <br /> REQUIRED PERSONAL PROTECTIVE <br /> Specific Site Information: <br /> : �D l �d a EQUIPMENT <br /> Z- <br /> Tank No. 0Tank Capacity <br /> Tank Contents: A,A,-' Tank Age: �rS <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> Type of Operation: unless appropriate rationale or restrictions are <br /> provided) . <br /> Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ J YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: ( ] YES [ J NO [ ] 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 /> Potential Health and Safetv <br /> Physical Concerns: (check all that apply & describe) <br /> ( J Heat or Cold Stress: of (high ambient temp.) <br /> ( J Noise Source: 2. Personal Protective Equipment <br /> ( J Oxygen Deficiency: Level of Protection: ( JA [ JB [ ]C ( ]D <br /> ( J Excavation: (falls, trips ,slipping, cave-ins) ( J Hard hat <br /> ( J Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, etc.) [ ] Steel coed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> ( J Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) ( J Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br />( J Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> Anticipated Biological Hazards: [ ] Two-way communication <br />( ] Snakes.- ( ] Insects [ J Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date: <br /> Plan Approved by-' Date: <br /> 12 <br />