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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EV7emicals <br /> N OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Hazards <br /> Address: 5 1/ !VP h ogens: <br /> Contact Person: RIM hinJLh, Phone No. 5 11 Ives: <br /> Sweeps Number. 11 GR [ sts: <br /> Proposed Date of investigation/inspection: (t/Y1�L [ �Flwanlmables: <br /> osives: <br /> [ <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] Ne ST Installation [ ] UAR Investigation [] Metals: <br /> [ J T4nk Closure in Place [ ] Tank/Pipe Repair [] Oxidizers: <br /> [ ank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> � PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: (/Q (J EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ins nts must be used for all operations <br /> 4. Type of Operation: lib Y l unle appropriate rationale or restrictions are <br /> pro 'ded) <br /> 5. Release History: [ Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] 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. P610i's'e <br /> l Health and Safety <br /> PConcerns: (check all that apply& describe) <br /> [ or Cold Stress: OF (high ambient temp.) <br /> [ Source: 2. Pers Protective Equipment <br /> [ ] en Deficiency: Lev Protection: [ ]A [ ]B []C [ <br /> [ cavation: (falls, trips ,slipping, cave-ins) rety <br /> hat <br /> [ andling and Transfer of a Hazardous Substance: glasses/goggles <br /> (fiEavy <br /> explosions, etc.) toed/shank shoes or boots <br /> [ ] ned Space entry. (explosions) [ ] Flame retardant coveralls <br /> equipment (physical injury& trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ J Other, specify A/P cartridge: <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 dikes, terrain, etc.): Plan Prepared by: Date: <br /> Plan Approved by: AJJ Date: <br /> EH23081 (2/7/92) �/ <br />