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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION { <br /> SITE HEALTH AND SAFETY PLAN 0 NT! :E !f Ii <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: a Poor D 1 1. Chemicals Hazards <br /> Address: Carcinogens: bedieaQ,422-' _ <br /> Contact Person:cAlyt,16bePhone N 670-7o-13.6 []Corrosives: .01 <br /> Sweeps Number. Eusts: <br /> Proposed Date of investigation/inspection: --oADOCd -Explosives: LG L. 4 tz.� <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases:-, <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> [ J Tank Closure in Place [] Tank/Pipe Repair [ ] Oxidizers: <br /> XTank/Pipe Removal [ ] Re-excavation []PCB's: <br /> ( j Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. ] Tank Capacity: _ 0 0 q EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ��® 1 instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History- ;¢Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ j YES [ ] NO [ ] Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ ] 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: b 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B []C sb6 <br /> Excavation: (falls, trips ,slipping, cave-ins) Df4iard hat <br /> andling and Transfer of a Hazardous Substance: ''Safety glasses/goggles <br /> (fire, explosions, etc.) C at.S I At,, Steel toed/shank shoes or boots <br /> ( ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> Heavy equipment (physical injury&trauma resulting Hearing protection <br /> from moving equipment) Gr^�C. �.[g2,/ a -2, [ ] Tyvek <br /> ( ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> afety vest <br /> 7. Anticipated Biological Hazards: NO N E [ ] Two-way communication <br /> [ J Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health ,�i d <br /> and Safety, e.g. power lines, ' e ty of dik s, terrain, etc.): Plan Prepared by: � Date: to <br /> Plan Approved b w Date <br /> EH23081 (2/7/92) <br />