Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: l�' � �'�{ ��£ -� "�� '`� �� 1. Chemicals Hazards <br /> Address: carcinogens: <br /> Contact Person: "<—Ti> ' `Phone No. -%-- - []Corrosives: <br /> Sweeps Number. Zh-6 [ ] Dusts: <br /> Proposed Date of investigation/inspection: [ losives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity. [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [Mals: <br /> [ ] T Closure in Place [ ] Tank/Pipe Repair [] Oxidizers: <br /> [,]'Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ J Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. i Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: V K <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: �mbustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ ] Photoionization Detector <br /> Background and description of any previous investigation [J 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 /> [ ] Or <br /> �gen Deficiency Le of Protection: [ ]A [ ]B [4C ]?� <br /> it_6cavation: (falls, trips ,slipping, cave-ins) (I Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ }'Safety glasses/goggles <br /> (fire, explosions, etc.) [Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Tame retardant coveralls <br /> ?]'Heavy equipment (physical injury& trauma resulting M Hearing protection <br /> from moving equipment) [4-t�vek <br /> [respirator, circle: �' or SCBA <br /> [ ] Other, specify A/P cartridge: �-t.'G <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dies, terrain, etc.): Plan Prepared by. 45'_ Date: ai/•= �� <br /> Plan Approved by: Dat _ <br /> EH23081 (2/7/92) <br />