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SANT JOAQUIN 4c'.)UNTY ENVIRONMENTTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLANT <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL. HAZARDS <br />1. Site Name: <br />Address: ' a <br />Contact Person: Phone No. <br />Sweeps Number. <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity. <br />[ ] New UST Installation (] UAR Investigation <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ ] jag ipe emov [ ] Re -excavation <br />[ ] Instal ation of Borings/Monitoring Wells <br />3. Specific Site Information: /P(` P; h <br />Tank No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Other: <br />4. Type of Operation: Q,05S <br />. Q- G `,., <br />5. Release History. <br />Evidence of leaks/soil contamination: (] YES (] NO <br />Documented Groundwater contamination:-[ ] YES [ ] NO <br />Background and desc 'ption of any previous investi ation <br />or incidence <br />®[ <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ I Heat or Cold Stress: of (high ambient temp.) <br />Noise Source: _ , <br />[ ] Oxygen Deficiency: <br />xcavation: (falls, trips ,slipping, cave-ins) <br />[ ] Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry. (explosions) <br />Heavy equipment (physical injury, & trauma resulting <br />from moving equipment), ,I , I7 <br />[ ] Other, specify <br />7. Anticipated Biological Hazards: <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />(] Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />C , l <br />EH23081 (2/7/92) <br />1. Chemicals Hazards <br />'Carcinogens• _ <br />[ ] Corrosives: . <br />Dusts: <br />Explosives: <br />Flammables• <br />(] Inorganic Gases: <br />[ ] Metals: <br />[ ] Oxidizers: <br />[ ] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />YE <br />ided) <br />ombustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />(] Organic Vapor Analyzer <br />[ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: [ ]A [ ]B [ ]C <br />Hard hat <br />[ ] Safety glasses/goggles <br />Leel toed/shank shoes or boots <br />[ ] ame retardant coveralls <br />Hearing protection <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: Date: — / —01 <br />Plan Approved by: Date: AL <br />