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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 EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: S\o, ��o.� ��� ��s 1. Chemicals Hazards <br /> Address: G -57- S o [,,Karcinogens: <br /> Contact Person: ,pc -r\cs Phone No. [corrosives: <br /> Sweeps Number. z 2 �, [ J Dusts: <br /> Proposed Date of investigado inspection: [ J Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrativ� of inspection activity. [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> ,/f 9"L c-"as 6�cH /.+si« PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity. EQUIPMENT <br /> Tank Contents: l 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 or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil cont ation: 111� [ ] N [ J Detector Tubes (Specify) <br /> Documented Groundwater con ination: [ J YES PrNO [ ] Photoionization Detector <br /> Background and description o any previous investigation [J Organic Vapor Analyzer <br /> or incidence: U �� r cess- [ ] Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area <br /> restrictions: <br /> �5 �) q vif%td � vl �G�O✓\ <br /> 6. Potential Health and Safety l� Jb-�c cti�lroHwr�� <br /> Physical Concerns: (check all at apply& describe) <br /> [ ] Heat or Cold Stress: OF (high ambient temp.) <br /> [.]'Noise Source: w,C. �,� e-\11 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency Level of Protection: [ ]A [ ]B [ JC [-T1S <br /> [ ] Ex vation: (falls, trips ,sli ping, cave-ins) <br /> [4'9andling and Transfer of a Hazardous Substance: [-]- ety glasses/goggles <br /> (fire, explosions, etc.) [,I-Steel toed/sharnk shoes or boots <br /> [ ] Confined Space entry. (exp osions) [ I Flame retardant coveralls <br /> [Meavy equipment (physical injury& trauma resulting [Hearing protection <br /> from moving equipment) [ I Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ J Insects [ J Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all informa 'on which could impact Health 2�7 y <br /> and Safety, e.g., power lines, ' tegriry/cf dikes, terrain, etc.): Plan Prepared by. Date: G- <br /> p� q �4 <br /> 4 Plan Approved by. 6�� Date: - y <br /> EH23081 (2/7/92) <br />