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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: J 9t l 1. Chemicals Hazards <br /> Address: <br /> 4 [carcinogens: <br /> Contact Person: a - hone No. [�C`orrosives: <br /> Sweeps Number: []Dusts: <br /> Proposed Date of investigation/inspection: [] plosives: <br /> [ lammables. <br /> 2. Description and brief narrative of inspection activity: []I rganic Gases: <br /> []New UST Installation []UAR Investigation etals: <br /> []Tank 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 /> REQUIRED PERSONAL PROTECTIVE <br /> 3. eci is Site ormatio <br /> n:ecin: EQUIPMENT <br /> Tank No. Tank Capacity: <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment:(note:Monitoring <br /> instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> 4. Type of Operation: J L provided) <br /> 5. Release History: []Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: []YES []NO []Detector Tubes(Specify) <br /> Documented Groundwater contamination: []YES []NO [] otoionizarion Detector <br /> phPhVapor Analyzer <br /> Background and description of any previous investigation []Organic specify: <br /> or incidence: []Other, p fy: <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: °F(high ambient temp.) 2. personal Protective Equipment <br /> []Noise Source: Lev of Protection: []A []B []C [ <br /> []Oxygen Deficiency: and hat <br /> []Excavation:(falls,trips,slipping,cave-ins) Neel <br /> fety glasses/goggles <br /> andling and Transfer of a Hazardous Substance: toed/s es/g shoes or boots <br /> (fire,explosions,etc.) <br /> []F me retardant coveralls <br /> []Confined Space entry:(explosions) Hearing protection <br /> []Heavy equipment(physical injury&trauma resulting []Hears <br /> from moving equipment) <br /> []Tyvek <br /> Respirator,circle: APR or SCBA <br /> []Other,specify cartridge: <br /> Safety vest <br /> 7. Anticipated Biological Hazards: <br /> []Two-way communication <br /> []Snakes []Insects []Rodents []Poisonous Plants PART IV <br /> []Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health plan Prepared by: Date: �r <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />