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SAl`l' 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: 1. Chemicals Hazards <br /> Address: [I Carcinogens: <br /> Contact Person: Phone No. (]Corrosives: <br /> Sweeps Number. ( ] Dusts: <br /> Proposed Date of investigationAnspecrion: [ ] Explosives: <br /> (j Flammables: <br /> 2. Description and brief narrative of inspection acriviry [ j Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair ( ] Oxidizers: <br /> [ I Tank/Pipe Removal [ j Re-excavation [1 PCB's: <br /> ( ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Soecific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <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 [ j Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( ] YES [ ] NO [ j Detector Tubes (Specify) <br /> Documented Groundware*contamination: [ j YES [ ] NO [ ] Photoionizarion Detector <br /> Background and description of any previous investigation (J Organic Vapor Analyzer <br /> or incidence: [ j Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restricrions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check ail that apply& describe) <br /> [ ] Heat or Cold Stress: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ j Oxygen Deficiency: Level of Protection: ( ]A [ IB ( IC ( ID <br /> [ I Excavation: (falls, trips ,slipping, cave-ins) ( j Hard hat <br /> [ j Handling and Transfer of a Hazardous Substance: [ ] Safety giasses/goggles <br /> (fire, explosions, etc.) [ J Steel toed/shank shoes or boors <br /> [ ] Confined Space entry. (explosions) [ I Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury& trauma resulting [ I Hearing protection <br /> from moving equipment) [ I Tyvek <br /> ( I Respirator, circle: APR or SCBA <br /> [ I Other, specify A/P cartridge: <br /> ( j Safety vest <br /> 7. Anticipated Biological Hazards: ( ] Two-way communication <br /> ( J Snakes [ I Insects [ I Rodents [ ] Poisonous Plants <br /> [ I Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by. Date: <br /> Plan Approved by: Dare: <br /> EH223081 (2/7/92) <br />