Laserfiche WebLink
SAINT JOAQIJLN COLTI'I'Y F- IRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAINT <br /> PART I PART U <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: _rJ ��. E / r'C> � 1. Chemicals Hazards <br /> Address: (] Carcinogens: <br /> Contact Person: hone No. [] Corrosives: <br /> Sweeps Number. d [ j Dusts: <br /> Proposed Date of investigado inspection: ( J Explosives: <br /> [] Flarornables: <br /> 2. Description and brief narrative of inspection activity_ [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [J Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ J Oxidizers: <br /> [ ] Tanl/Pipe Removal [ j Re-excavation (] PCB's- <br /> [ ] I4stallation of Borings/Mo 'toren Wells <br /> fr7�I tam GUct Sfe- 9CQz 9 Zvi S�f7lJvv PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> ins-Sens must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History-. [ J Combustible Gas/Oxygen Mete_* <br /> Evidence of leaks/soil con anon: [ ] YES ( ] NO ( ] Detector Tubes (Specify) <br /> Docurne_*ited Groundwater contamination: [ ] YES [ ] NO [ j Photoiorization Detector <br /> Background and description o any previous investigation (J Organic Vapor Analyze.* <br /> or incidence: [ j Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or ac '* /area restrictions: <br /> 'Yu ` <br /> 6. Potential Health and Safety J . a. <br /> Physical Concerns: (check all at apply & describe) - <br /> ( ] Heat or Cold Stress: of (high ambient temp.) %`�� �` y 4 .� <br /> [ ] Noise Source: 'r" 2- Personal Protective Equipment <br /> ( j Oxygen Deficiency Level of Protection: [ ]A [ ]B [ ]C AD <br /> QJEaIIs, traps ,s pin cave-ins) QJ.Hard hat <br /> [ j Handling and Transfer or'a Faiardous Substance: ,KSafery glasses/goggies <br /> (fire, explosions, etc) [ ] Steel coed/shank shoes or boots <br /> ( ] Confined Space entry. (explosions) ( j Flame retardant coveralls <br /> Heavy equipment (physical injury& trauma resultingHearing protection <br /> from moving Equipment) f �� 5 ( ] Tyve_k <br /> [ ] Respirator, circle: APR or SC3A <br /> [ ] Other, specify eiezc A/P cartridge: <br /> XSafery vest <br /> 7. Anticipated Biological Hazards: [ j Two-way communication <br /> [ ] Snakes [ ] Insecs ( ] Rodents [ ] Poisonous Plants <br /> ( ] Other/Unknown (specify): PART N <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safery, e.g., power Lines, ' tegrity of dikes, terrain, etc.): Pian Prepared by- '',gji Date: e <br /> Cq— C;1 Pian:approved by. Date: <br /> G,)G2 <br /> EH23081 (2/7/92) <br />