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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SrM HEALTH AND SAFETY PLAN <br /> PART PART II <br /> GENERAL SrTE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: Carcinogens: <br /> Contact Person: Phone No. Corrosives: <br /> Sweeps Number. Dusts: <br /> Proposed Date of investigation/' on: Explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity. Inorganic Gases: <br /> I New UST Installation ] UAR,Investigation Metals: <br /> I Tank Closure in Place I Tank/Pipe Repair Oxidizers: <br /> I Tank/Pipe Removal I Re-excavation PCB's: <br /> I Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity- EQUIPMENT <br /> Tank Contents: Tank Age: <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 /> provided) <br /> S. Release History. I Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [ ] NO I Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( ] NO I Photoionization Detector <br /> Background and description of any previous investigation I Organic Vapor Analyzer <br /> or incidence: I 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 [ ]D <br /> Excavation: (falls, trips ,slipping, cave-ins) I Hard hat <br /> Handling and Transfer of a Hazardous Substance: I Safety glasses/goggles <br /> (fire, explosions, etc.) I Steel toed/shank shoes or boots <br /> Confined Space entry- (explosions) I Flame retardant coveralls <br /> Heavy equipment (physical injury&trauma resulting I Hearing protection <br /> from moving equipment) I Tyvek <br /> I Respirator, circle: APR or SCBA <br /> Other, specify A/P cartridge: <br /> I Safety vest <br /> 7. Anticipated Biological Hazards: I Two-way communication <br /> Snakes [] Insects [ I Rodents Poisonous Plants <br /> 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: <br /> Plan Approved by. Date: <br /> EH23081 (2/7/92) <br /> hhhl� A <br />