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AMA <br /> SHIN JOAQUIN COU-N= EN-VMO?-MENTAL IMAI.TH DIVLSION <br /> SIT r =ALTH ANL D SAFETY PT—Aaq <br /> PART I PART U <br /> GENERAL SITE ngFORMATION EVAL=ON OF POTMT AL HAZARDS <br /> i. Site Name: 1. Chemicals Hazards <br /> Address: Z > [I Carcinogens: <br /> Contact P=oa:.:& r Phone No. ® 6 Z-5„7 [j Corrosives- <br /> Sweeps Numbe-n 3 [1 = . <br /> Proposed Date of invesdgarion/inspecdon: Y plosives: <br /> 44'n ables: <br /> 2. Desciprion and 'brief, nartauve or inspection acdviry: ( ] Inorganic Cases: <br /> ( I New UST Installation (] UAR Investigationals: <br /> [ I T ank Closure in Place [j Tank/Pipe Repair NI'MM'dizears: <br /> rj,7_1an.VPipe Removal (] Re-r=cavation [1 PCB's: <br /> ( ] Installation or Borizzgs/Monitoriag Wells <br /> PART III <br /> 3. Speck Site Iniormadon: REQDIRF.D PMRSONAL PROTECTIVE <br /> Tank No. L^ Tank Capaciry. ®®L EQUIPMEN-. <br /> Tank Contents: P® ank Age.• <br /> Otzen 1. Monirorng Equipment+ (note: Monitoring <br /> a • as.:.:ments must be used for all ope*arions <br /> ?. Type of Cpe_�tioa: S '�vrG unless avoroptiare:ar onaie or--es—,-,c--;ons are <br /> 'orovided) <br /> S. Release History. NCo=buzzE7bIe Gas/Oxygen Meter <br /> --riden-ce of leaks/soil contamination: [ j MS ( j NO [ Detector Tubes (Specify) <br /> Doc+neared Groundwater contamination: [ ] YES ( ] NO ( ? Photoionizadon Detector <br /> Background and des=..ion or any previous !=7esdgazon [] Organic Vapor Amaiyza <br /> or incidence: ( I Other, speciy: <br /> If=onitorng irsa:netts are not used, <br /> eztionale or activirr//area res-:cn'oru: <br /> b. Potential Healtd and Safety <br /> Physical Cance—ms: (check ail than apply & descbe) <br /> [ ] rear or Cold St'ess: °F'(high ambient tem. <br /> (b)-Noise Source: G 2. Personal Pratec ve Ec iumenr <br /> ( I Oxygen Deficiency: Level of Protection: (IA [ IB KC fr3D <br /> ME_xcavzrion: (falls, ups ,siippi Io cave-ills) :Eard har <br /> [ ] Handling and Transfer of a Hazardous Substance: ] Safety glasses/gogQ es <br /> (fire, e=iosiors, etc.) Steel toed/shank shoes or boors <br /> ( ] Confined Space entry: (explosions) [ ] ::ame retardant coveralls <br /> reavy equipment (physical injury& =uma resulting ,-fearing protec,on <br /> "tom moving equipmenr) Tgvek <br /> Respirator, circle: r SC3A <br /> [ j Other, specify A/P mrciidge: <br /> [ ] Safety vest <br /> T. Anticipated Biologic:d Hazards: [ ] Two-way communication <br /> [ ] Snakes [ I Insects [ ] Rodents [ j Poisonous Plants <br /> [ ] Ot7e_-/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide ai? inforanarion which could impact Heals <br /> and Safety, e.g., Powe_-lines, integr r/of disces, te-+-min, etc.): Plan ?repared by. D - �21 <br /> .ate. <br /> Plat approved by. Date. <br /> .23081 (2/7/92) <br />