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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART U <br /> GENERAL SITE WORMATION ( EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: P.� J 1. Chemicals Hazards <br /> Address: [] Carcinogens: <br /> Contact Person: Pho a No. �Z [] Corrosives: <br /> Sweeps Number Y9 ( ] Dusts: <br /> Proposed Date of investigation/inspection: [ ] Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity. [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [ ] Metals: <br /> ( ] Ti�tt Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> Q.J Tank/Pipe Removal [ ] Re-excavarion <br /> [] PCB's- <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site ormadon: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. I/ Tank Capacity: EQUIPMENT <br /> Tank Contents: (/f}So/i/� - Tank Age: -- <br /> Other. 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale orrestrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/song contamination: [ ] YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] 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 /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> [ ] Heat or Cold Stress: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment / <br /> [ ] Oxygen Deficiency: Lev of Projection: [ ]A [ ]B [ ]C [GfD <br /> ( ] Excavation: (falls, trips ,slipping, cave-ins) [ at <br /> [ ] Handling and Transfer of a Hazardous Substance: [ afery glasses/goggles <br /> (fire, explosions, etc) [ ] Steel toed/shank shoes or boors <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] T,tek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify <br /> A/P cartridge: <br /> ( ] Safery vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVA". *�e4I)are:and Safety, e.g., power lines, integrity of dikes, terrain, etc): Plan Prepared � r <br /> Plan Approved brq Date: - <br /> FH23081 (2/7/92) <br />