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w <br /> SAN J AQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATIC N EVALUATION OF POTENTIAL HAZARDS <br /> <--1 - / <br /> Site Name: Vcl �� 6'-b h1 Er S �1f 1. Chemicals Hazards <br /> Address: " M I Rk ['Carcinogen: <br /> 1ontact Person: 'rt Y Phone No. i S�j� :]Corrosives: <br /> u Sweeps Number: ']Dusts: <br /> Proposed Date of investigation/ spection: ]Explosives: <br /> [kj Flammables: <br /> 2. Description and brief narrative of inspection activity: [l'J Inorganic Gases: <br /> []New UST Installation []UAR Investigation Metals: <br /> []Tank Closure in Place []T mkfPipe Repair Oxidizers: <br /> []Tank/Pipe Removal [] -excavation [k]PCB's: <br /> []Installation of Borings/Monitoring Wells <br /> V.� (�'.�� to e� c' 0),-% PART III <br /> 3. Specific Site I ormat n: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment:(note:Monitoring <br /> f_, instruments must be used for all operations <br /> 4. Type of Operation: �� M +V r unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: []Combustible 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 [] Organic Vaporer <br /> or incidence: [Iq Other,specify: <br /> 17eIf monitoring instruments are n used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all th it apply&describe) <br /> }Heat or Cold Stress: °F(high ambient temp.) <br /> PI,Noise Source:_ 2. Personal Protective Equipment <br /> Oxygen Deficiency: Level of Protection: []A []B []C Mb <br /> []Excavation:(falls,trips slipping,cave-ins) V14ard hat <br /> 'X�Handling and Transfer of a Hazardous Substance: $4 Safety glasses/goggles <br /> (fire,explosions,etc.) N Steel toed/shank shoes or boots <br /> []Confined Space entry:(explo ions) []Flame retardant coveralls <br /> []Heavy equipment(physical' jury&trauma resulting Hearing protection <br /> from moving equipment) >]Tyvek <br /> Respirator,circle: Al' or SCBA <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 IV <br /> PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health <br /> sI <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): Plan Prepared by: ADate: v r <br /> &� <br /> Plan Approved by: Date:4A� <br /> EH23081 (2/7/92) <br />