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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE WORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: C.s 1. Chemicals Hazards <br /> Address: Carcinogens: <br /> Contact Person: Phone N6. Corrosives: <br /> Sweeps Number. / /a Dusts: % g . <br /> Proposed Date of investigation/inspection: ( t) 9 J Explosives: <br /> [J Flammables• <br /> 2. Description and brief narrative of inspection activity: [ J Inorganic Gases: <br /> New UST Installation [ J UAR Investigation [] Metals: <br /> ank Closure in Place [ ] Tank/Pipe Repair [] Oxidizers: <br /> [ Tank/Pipe Removal [ ] Re-excavation (]PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No.0/)4�2 *5 Tank Capacity: 5,660 EQUIPMENT <br /> Tank Contents: ; Tank Age: r <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: / unless appropriate rationale or restrictions are <br /> P provided) <br /> S. Release Histo . Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: YES [I NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES NO [ ] Photoionization Detector <br /> Background and description of any previous roves ' tion [J Organic Vapor Analyzer <br /> o incidence: c� L° _ _ _ [ l 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 /> Noise Source: �'_ / 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C <br /> Excavation: (falls, trips ,slipping, cave-ins) r and hat <br /> [ ] andling and Transfer of a Hazardous Substance: Mafety glasses/goggles <br /> (fire, explosions, etc.) Leel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> Heavy equipment (physical injury&trauma resulting Baring protection <br /> from moving equipment) " (/g2 _ [ I Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> afety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ I Other/Unknown (specify): 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.): Plan Prepared by: Date:Alo� <br /> f` .S r t.r— ® vyr— <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />