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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: 1W S(n ;2c QQg„u QMf=::- 1. Chemicals Hazards <br /> Address: 13A Carcinogens: <br /> Contact Person: Phone No. yCL 2. y6",01 [ Corrosives: <br /> Sweeps Number. [ ] Dusts: <br /> Proposed Date of investigation/inspection: - [ j Explosives: <br /> [] Flammables• <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ j UAR Investigation [Q Metals: Q C 6 <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [] Oxidizers: <br /> [rnTank/Pipe Removal ( j Re-excavation []PCB's- <br /> ( ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. 4 Tank Capacity: fb EQUIPMENT <br /> Tank.Contents: i �,,1� Tank Age: /Q <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be.used for all operations <br /> 4. Type of Operation: [�oa,�( �a ( � �-� unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] S ( j NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ S [ ] NO [ ] Photoionization 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 /> b. Potential Health and Safety <br /> Physical Concerns: (check all that apply& describe) <br /> ( ] Heat or Cold Stress: OF (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] 0 en Deficiency. Level of Protection: [ ]A [ ]B []C XD <br /> Kation: (falls, trips ,slipping, cave-ins) [ ] Hard hat <br /> ( Handl' and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> explosions, etc.) f,Steel toed/shank shoes or boots ` <br /> [ ed Space entry: (explosions) [ j Flame retardant coveralls <br /> [ Heavy equipment (physical injury& trauma resulting [ j Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ j Other, specify A/P cartridge: <br /> Safety vest <br /> 7. Anticipated Bio 'cal HazarAe" [ Two-way communication <br /> [ ] Snakes [ Insects [•Rodents [ ] Poisonous Plants <br /> [ j Other/Unknown (specify)• PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health ✓'���,/ <br /> and Safety, e.g., p wer lines, integrity of dikes, terrain, etc.): Plan Prepared by: w\ _Date: �7 <br /> Plan Approved by Date:-�/re~,%— <br /> EH23081 (2/7/92) <br />