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SAKI' JOAQUIN COUN'T'Y EN-VIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PIAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: &4 <br />Address: 2Za <br />Contact Person: eIAW, y Phone N / -L/ <br />Sweeps Number. <br />Proposed Dare of investigarion/inspection: v/G <br />2. Description and brief narrative of inspection activiry: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ j Tank Closure in Place [ ] Tank/Pipe Repair <br />�Tank/Pipe Removal [ ] Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />3. Specific Site Inf nnarion: <br />Tank No. rf Tank Capacity: 5MCy/ <br />Tank Contents: W�2 Tank Age:y� <br />Other: <br />4. Type of Operation: -r4 72,01 if+ C61, <br />5. Release History: <br />Evidence of leaks/soil contamination: [ ] YES [ ]NO <br />Documented Groundwater contamination: [ ] YES [ I NO <br />Background and description of any previous investigation <br />or incidence: <br />6. :Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />(Heat or Cold Stress: "`civ of (high ambient temp.) <br />Noise Source: 94e- <br />[ ] Oxygen Deficiency: <br />f llxciavadon: (falls, trips ,slipping, cave-ins) <br />[ ] dling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ j Confined Space entry. (explosions) <br />Heavy equipment (physical injury & trauma resulting <br />1"14om moving equipment)_ r6 <br />[ ] Other, specify <br />7. Anticipated Biological Hazards: <br />C 1 Snakes [ ] Insects C ] Rodents <br />[ ] Other/Unknown (specify): <br />[ ] Poisonous PIants <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integriry of dikes, terrain, etc.): <br />EH23081 (2/7/92) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />[I Carcinogens: <br />[ j Corrosives- <br />[ ] Dusts: <br />[ ] <br />Explosives: <br />'t,-;,Fiammables• <br />[ ] Inorganic Gases: <br />Merals.. <br />(j Oxidizers: <br />[ 1 PCB's: <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />Provided) <br />Combustible Gas/Oxygen Metes <br />[ j Detector Tubes (Specify) <br />[ ] Photoionizarion Detector <br />[ j Organic Vapor Analyzer <br />[ 1 Other, specify: <br />If monitoring instruments are not used, <br />rationale or acriviry /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: [ ]A [ ]B TqC YH <br />(�] Hard hat / <br />[ Safety glasses/goggies <br />Cq Steel toed/shank shoes or boors <br />[ ] Flame rerardanr coveralls <br />Hearing protection <br />Tyve-k <br />E.] Respirator, circle: or SCBA <br />A/P cartridge: ,r <br />[] Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by .. Date: <br />Plan Approved by. Date: <br />