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SAN JOAQUIN COUN t Y ENVIRONMENTAL HEALTH <br />JISION <br />SITE HEALTH AND SAFETY PLAN <br />,RT I <br />.,ENERAL SITE INFORMATION <br />.. Site Name: <br />Address: <br />Contact Person: Phone No. <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />J New UST Installation [ ] UAR Investigation <br />(] Tank Closure in Place [) Tank/Pipe Repair <br />[ J Tank/Pipe Removal [ ] Re -excavation <br />[) Installation of Borings/Monitoring Wells <br />3. Specific Site Information: <br />Tank No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Other: <br />4. Type of Operation: <br />W <br />Release History: <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />Background and description of any previous investigation <br />or incidence: <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[) Heat or Cold Stress: of (high ambient temp.) <br />[ J Noise Source: <br />[ j Oxygen Deficiency: <br />[ J Excavation: (falls, trips ,slipping, cave-ins) <br />[ ] Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ j Confined Space entry: (explosions) <br />[ ] Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />[ ] Other, specify <br />7. Anticipated Biological Hazards: <br />[ ] Snakes; [) Insects [ ] Rodents <br />[ ] Other/Unknown (specify): <br />[ ] Poisonous Plants <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />12 <br />PART 11 <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />[ ] <br />Carcinogens: <br />[ ] <br />Corrosives: <br />[ ] Dusts: <br />[ ] <br />Explosives: <br />(] Flammables: <br />[ ] Inorganic Gases: <br />[ ] <br />Metals: <br />(] <br />Oxidizers: <br />[ ] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <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 Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ J Organic Vapor Analyzer <br />[ J Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: [ JA [ )B ( ]C [ ]D <br />[ ] Hard hat <br />[ ] Safety glasses/goggles <br />(] Steel toed/shank shoes or boots <br />[ J Flame retardant coveralls <br />[ ] Hearing protection <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />[ J Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: <br />Plan Approved by: <br />Date: <br />Date: <br />