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0 0 i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: C 0 "'t 1. Chemicals Hazards <br /> Address: /� s e Carcinogens: <br /> Contact Person: Phone No. []Corrosives: IV <br /> Sweeps Number. /l Dusts: cam@ � ;�, <br /> Proposed Date of investigation/inspection: 41j&4 12D E<Explosives: r <br /> ammables• <br /> 2. Description and brief narrative of inspection activity: [Tr <br /> organic Ga' s: <br /> New UST Installation AR Investigation etals: <br /> ? Tank Closure in Place [ ] Tank/Pipe Repair [] 'dizers• <br /> ank/Pipe Removal [ ] Re-excavation 6'"[1 PCB's: t 6 <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: )j b W cB 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: e9 11, S7a L9., unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History. XM <br /> Combustible Gas/Oxygen Meter <br /> Evidence of leaks/sod contamination: [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: ( ] YES j ] NO [ ] Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: 04 L-te, 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 /> 1 11 A Heat or Cold Stress: of (high ambient temp.) <br /> Noise Source: l � 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A ( ]B [ ]C XD <br /> cavation: (falls, trips ,slipping, cave-ins) �; E1 Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boots <br /> [ 1 Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> eavy equipment (physical injury&trauma resulting *Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> aspirator, circle: R or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ l 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: ate: <br /> Plan Approved by:e -date: / <br /> EH23081 (2/7/92) <br />