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A <br /> SAN JOAQUIN COUNTY ENVIRO-,-%-1ENT AL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE L1iFORti1ATION EV.AI.UATION OF POTENTIALFLAZ,ARDS <br /> I. Site Name: ` t�C O Cer S 1. Chemicals 14azards <br /> [ cinogens: <br /> Address p <br /> one No. orrosives: <br /> Contact Person: [)Dusts: <br /> Sweeps Number: []Explosives: <br /> Proposed Date of investigation/inspection: amrnables: <br /> [) ganic Gases: <br /> I r <br /> 2. Description and brief narrative of inspection activity: etals: <br /> []New UST Installation []UAR Investigation [)Oxidizers: <br /> []Tank Closure in Place []Tank/Pipe Repair PCB's: <br /> ()Tank/Pipe Removal [)Re-excavation <br /> [)I tallation of Bo ' gsMonitoring Wells PART III <br /> 3. ci is Site Info tion: REQUIRED PERSONAL PROTECTIVE <br /> Tank Capacity: EQUIPi✓IENT <br /> Tank No. <br /> Tank Contents: Tank Age: <br /> 1. Monitoring Equipment:(note:Monitoring <br /> Other: instruments must be used for all operations <br /> P <br /> 4. Type of Operation: �; unless appropriate rationale or restrictions are <br /> y provided) <br /> []Combustible Gas' <br /> !Oxygen Nleter <br /> 5. Release History: [)Detector Tubes(Specify) <br /> Evidence of leaks/soil contamination: []YES []NO (�Photoionization Detector <br /> Documented Groundwater contamination: [)YES [)NO [)Organic Vapor Analyzer <br /> Background and description of any previous investigation [)Other,specify: <br /> or incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply&describe) <br /> [] or, Cold Stress: OF(high ambient temp.) <br /> oise Source: 2. Personal Protective Equipment <br /> [ <br /> []Oxygen Deficiency: el of Protection: []A []B [JC <br /> and hat <br /> L <br /> []Ex vation:(falls,trips,slipping,cave-ins) afety glasses/goggles <br /> andling and Transfer of a Hazardous Substance: Steel toed/shank shoes or boots <br /> (fire,explosions,etc.) []Flame retardant coveralls <br /> []Confined Space entry:(explosions) [rearing protection <br /> []Heavy equipment(physical injury&trauma resulting []Tyvek <br /> from moving equipment) (]Respirator,circle: APR or SCBA <br /> cartridge: <br /> []Other,specify 144afety vest <br /> []Two-way communication <br /> 7. Anticipated Biological Hazards: <br /> []Snakes []Insects []Rodents [)Poisonous Plants PART IV <br /> []Other/Unknown(specify): PLAN APPROVAL <br /> do <br /> 8. Narrative(provide all information which could impact Health �� ' <br /> Plan Prepared by: ate: <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): ___ <br /> Plan Approved by: <br /> Date: 7 <br /> EH23081 (2/7/92) <br />