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SAN JOAQUIN COUNNDTY ENVIRONMENTAL HEALTH* <br />T/1VISION <br />SITE HEALTH AND SAFETY PLAN <br />`ARTI <br />.ERAL SITE INFORMATION <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />7. Site Name: <br />1. Chemicals Hazards <br />Address: <br />Carcinogens: <br />Contact Person: Phone No. <br />Corrosives: <br />Sweeps Number: <br />Dusts: <br />Proposed Date of investigation/inspection: <br />Explosives: <br />Flammables: <br />2. Description and brief narrative of inspection activity: <br />Inorganic Gases: <br />New UST Installation UAR Investigation <br />Metals: <br />Tank Closure in Place Tank/Pipe Repair <br />Oxidizers: <br />Tank/Pipe Removal Re -excavation <br />PCB's: <br />Installation of Borings/Monitoring Wells <br />PART III <br />3. Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. Tank Capacity: <br />EQUIPMENT <br />Tank Contents: Tank Age: <br />1. Monitoring Equipment: (note: Monitoring <br />Other: <br />instruments must be used for all operations <br />i. Type of Operation: <br />unless appropriate rationale or restrictions are <br />provided) <br />5. Release History: <br />combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: []YES []NO <br />Detector Tubes (Specify) <br />Documented Groundwater contamination: ( I YES [ ] NO <br />Photoionization Detector <br />Background and description of any previous investigation <br />Organic Vapor Analyzer <br />or incidence: <br />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 />Heat or Cold Stress: OF (high ambient temp.) <br />2. Personal Protective Equipment <br />Noise Source: Oxygen Deficiency: <br />Level of Protection: [ ]A [ ]B ( ]C ]D <br />Excavation: (falls, trips slipping, cave-ins) <br />Handling and Transfer of a Hazardous Substance: <br />C Hard hat <br />[ Safety glasses/goggles <br />(fire, explosions, etc.) <br />[ Steel toed/shank shoes or boots <br />Confined Space entry: (explosions) <br />C Flame retardant coveralls <br />Heavy equipment (physical injury & trauma resulting <br />[ Hearing protection <br />from moving equipment) <br />Tyvek <br />Respirator, circle: APR or SCBA <br />Other, specify <br />A/P cartridge: <br />Safety vest <br />7. Anticipated Biological Hazards: <br />Two-way communication <br />Snakes; ( ) Insects [ ] Rodents Poisonous Plants <br />Other/Unknown (specify): <br />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.): <br />Plan Prepared by: Date: <br />Plan Approved by: Date: <br />12 <br />