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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL.HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: [] Carcinogens: <br /> Contact Person: Phone No. [J Corrosives: <br /> Sweeps Number. C l Dusts: <br /> Proposed Date of iavestigarion/inspecrion: [ ] Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [ ] Metals: <br /> [] Tank Closure in Place [ ] Tank/Pipe Repair [ j Oxidizers: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation [j PCB's- <br /> [ ] Installation of Borings/Monitaring Wells <br /> PART III <br /> 3. Soecific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacty: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> instrumenrs must be used for all operations <br /> ?. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ ] Phoroionization 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. Pocencial Health and Safety <br /> Physical Concerns: (check all that apply& describe) <br /> [ ] Hear or Cold Stress: of (high ambient temp.) <br /> ( ] Noise Source: 2- Personal Protective Equipment <br /> ( ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C [ ]D <br /> [ ] Excavation: (falls, trips slipping, cave-ins) [ ] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, erc.) [ ] 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) ( ] Tyve-k <br /> [ ] Respirator, circle: APR or SC3A <br /> [ ] 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 N <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of duces, terrain, etc.): Plan Prepared by. Date: <br /> PlanApproved by. Dare: <br /> EI13081 (2/7/92) <br />