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6 0 <br /> SAN JOAQUIN COLTv'I'Y EVU:,'O?'gIfEN AL =E AL.TH DIVISION <br /> SITE HEAL 7H ,HYD SAE= PLAN <br /> PART I PART U <br /> GENERAL SMm INTOR =ON EVALUAIION OF POTENTIAL F—AZARDS <br /> L Size Name: {cjt� L �Chh Gals Hazards <br /> ..4 <br /> Address: kLoC �_ ��.:5 v� Y! - Mogi' <br /> Contac:Pe-'son: L m blo(K)g* Phone No []Corrosives: <br /> Sweeps Number: L 1 Dusts: <br /> Proposed Date or investigarion/iasaecrion: t,AgV44owaar ( ] = losivs: <br /> 2. Desc=mtion and 'brie;nazrat ve of inspection ac=Mrr.. [ ] organic Cases: <br /> [ l New UST installadon ( ] UAR invesmigadon [ 1Qemis: <br /> [ ] Closure in Place [ ] Tank/Pipe Repair [ ] O:.-idizers: <br /> [ TamK/Pipe Removai [ ] Re-excavamon [l PCB'S: <br /> [ ] irstzllarion or Bor zzp/Moniroring Wets <br /> P AR T III <br /> 3. Soeciec Site in*otmarion: REQUIRED PI—ERSONAL PROTECiTVE <br /> lank No. { lank Ca-paciry: 6M EQULPN=1 <br /> T3P K COnt2.^_LS: t '�.ajjr- er I/ 1 ank Aga' <br /> Ctmer: ?. Monitor-ng S uDmenz (note: Moniroring <br /> s=-=e=rs =':SL be used for all ope_a ons <br /> Type or Operation: unless aDDroor:are-adoaaie or=es--:c-ons are <br /> pro - edj <br /> 5. Reiease History- -/Z Combustible Gas/Oxygen Mere: <br /> ,,idence of leaks/sail conra^TnArion: :NO [ 1 De_emor rubes (Spee) <br /> Dome--Led Gro—d—water contam=ination: [ ] "MS j,]-NO [ 1 Phozoio +*tat on Detector <br /> Back,ound and desc pdon of any previous invesrigazioa [I Organic Vapor A.naiyzer <br /> or incidence: L I Ozser, spec.rr. <br /> if yonirce=g ,T, ==e^rts are morused, <br /> rationale or ac=vity/area resm:c_ons: <br /> 5. Po cenria Heaiz and Safety <br /> Physical Cance_^..s: Cc:--e--k all :har apply & descDe; <br /> [ l -ear or Cold Stress: °= (high ar<:biezz temp.) <br /> [-":Noise Source: A- 2 Penonai Protec*.dve Spuipmenr <br /> �n Deficiet:c Le/v ' of Prole ton: [lA [ IB [ IC /JD <br /> [ 1 O .cavadon: (falls, Sips ,siippmg cave-ins) jj j Hard 'oat <br /> [�andhng and Transfer or a r_— rdous Substance: [ j ,Sale=y o asses/goggles <br /> (Ere, explosions, etc.) [ , Steel coed/shank shoes or boors <br /> [ ] <br /> corraned Space em=-)r (espiosions) [ ] 5—,,=e rerard=r coveralls <br /> .Heavy e=-Dmenr (pnysicai injury& trauma resulting [,}' =, g protection <br /> Erom moving equipment) L l Tyve-Ic <br /> [ I Respirator, circle: APR or SCBA <br /> L 1 Other, specify A/P c^dge: <br /> L I Safe y vest <br /> 7. Anticipated 3io i "r:azar' : [ J Two-way co=, =car-or- <br /> Snakes <br /> canon <br /> [ ] Snakes insectsI[ I Poisonous Plants <br /> L I Other/Unianomm (specify): PART IV <br /> pT„e,N 'APPROVAL <br /> 8. Nararive Cprovide aill informarion which could bmpac Heap <br /> and Sate_^, e_g., oW T^es, nL �L�7 or d:.Kes, :et=31n, rG)_ ':)I Prey ared by Date: <br /> yp-� <br /> Wan approved by. ._ Date: <br /> 2308IZ-HC=/7/921 <br />