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SAN JOAQUhN COUNTY ENVMONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART a <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address- [I Carcinogens: <br /> Contact Person: hone No. (] Corrosives: <br /> Number 13 (] Dusts: <br /> Proposed Date of investigation/inspection: [j Explosives: <br /> q.lFlammables: <br /> 2. Description and brief narrative of inspection activity: [j Inorganic Gases: <br /> ININew UST Installation (j UAR Investigation etals: <br /> (] Tank Closure in Place (] Tank/Pipe Repair [] Oxidizers- <br /> Tank/Pipe Removal (] Re-excavation []PCB's: <br /> (] nstallation of Borings/Monitoring Wells <br /> PART ild <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: 1005VUleEQUIPMENT <br /> Tank Contents: _ Tank Age: A% <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: ® ®� unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: ombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: (] YES (] NO (I Detector Tubes (Specify) <br /> Documented Groundwater contamination: (] YES (I 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 /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> (j Heat or Cold Stress. °F (hi h ambient temp.) <br /> r1oxygen <br /> oise Source: r 2. Personal Protective Equipment <br /> Deficiency: . Level of Protection: <br /> []A [IB C;K yo <br /> cavation: (falls, trips ,slipping, cave-ins) WHard hat <br /> [] Handling and Transfer of a Hazardous Substance-. afery glasses/goggles <br /> (fire, explosions, etc.) IT Steel toed/shank shoes or boots <br /> [j Confined Space entry: (explosions) [j Flame retardant coveralls <br /> Heavy equipment (physical injury & trauma resulting Hearing protection <br /> 'from moving equipment) -0 Tyvek <br /> [] Other, specify JJAespirator, circle: 1P <br /> or SCSA <br /> A/P cartridge: <br /> vest <br /> ve <br /> 7. Anticipated Biological Hazards: ( Safety ety ve communication <br /> [] Snakes (] Insects (] Rodents (] Poisonous Plants <br /> [I Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PIAN APPROVAL <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: --'' 0ate:ZJJ,7 <br /> Plan Approved by: Date <br /> EH23081 (2/7/92) <br />