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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />PART 11 <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: /-�,�z e/,¢„? <br />Address: /9-/O <br />Contact Person: Phone No. gel& r - 3iv y <br />Sweeps Number. ii yi <br />Proposed Date of investigation/inspection: <br />2. <br />Description and brief narrative of inspection activity: <br />[ J Inorganic Gases: <br />[ J New UST Installation [ J Ute& Investigation <br />[ J Metals:.,- F <br />[ ] Ta-ik Cloe»re in Place [ ank/Pipe Repair <br />[ J Oxidizers• <br />Re -excavation <br />C GCB's• <br />�Y:nstaiiaao� of Borings/Monitoring Wells <br />- <br />PART III <br />3. <br />Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE <br />wo �� <br />Tank No. ll0/ Tank Capacity: lam, p�„Y <br />EQUIPMENT <br />Tank Contents: ?IeWq rho Tank Age: Ll/ <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />4. <br />Type of Operation: c/ <br />unless appy ate rationale or restrictions are <br />provi ��„ <br />S. <br />Release History: <br />[a mbustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination:[ (J� <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES O <br />[ ] Photoionization Detector <br />Background and description of any previous investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: M % k s-1 4 2 � ) <br />c <br />[ ] Other, specify: <br />C117SIf <br />monitoring instruments are not used, <br />•-y� <br />rationale or activity /area restrictions: <br />6. <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ]• t or Cold Stress: of (high ambient temp.) <br />otse urce: <br />2. Personal Protective Equipment <br />[ ] en Deficiency: <br />Lev Protection: [ ]A [ ]B [ ]C [ ]D <br />[ cavation: (falls, trips ,slipping, cave-ins) <br />t <br />[ ] Handling and Transfer of a Hazardous Substance: <br />[ glasses/goggles <br />(fuef4iplosions, etc.) <br />[ teel toe shank shoes or boots <br />[ ], Confined Space entry. (explosions) <br />[ ] Fl retardant coveralls <br />Heavy equipment (physical injury & trauma resulting <br />earing protection <br />from moving equipment) <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] Other, specify <br />A/P cartridge: <br />[ ]Safety vest <br />7. <br />Antic' ted Biological Hazards: <br />8i <br />(]Two-way communication <br />V-Slfia-kes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />8. <br />Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by. '' ate:o� <br />Plan Approved by: Date: <br />EH23081 (2/7/92) <br />