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SA.N JOAQUJIN C0TJ- Y EN-N.RO?N1i rMN� AL, Fes' -kL.TH DIVISION <br />SITE HEALTH AND SAFETY PLAIN <br />? ART I <br />Gm, R SITE 24FORM&MON <br />PART U <br />EVALUATION OF POTENTIAL F—AZARDS <br />1. Site Name- <br />I_ Chemicals Hazards <br />Address: <br />[I Carcinogens: <br />Contac: Person: Phone No. <br />(j Corrosives: <br />Sweeps Number: <br />[ 1 Dusts' <br />Proposed Dare of investigaton/i=ez ion: <br />(I Plosives: <br />[ Jrlammables: <br />2. Desciption and 'brief narrative of i speer on <br />Inorganic Cases: <br />[ I New UST instatiacon [ j UAR Invest€garion <br />[ j Metals: <br />[ I Tank Closure in Place [ I Tank/Pipe Repair, <br />(I Oazdizer= <br />[ I Tank/Pipe Removal [ J Re -excavation <br />[ J PCB's: <br />[ J Irstallanon of Borizags/Monitoring Wells <br />PART IL <br />3. Sbecinc Site Gln or=ation: <br />REQL= PERSONAL PROTEECTM <br />_nk No. Tank Capacity. <br />EQUIPMD T <br />an Conrears: T anis Age: <br />Otter: <br />1. Moniroriin cuiDmenL (note: Monitoring <br />\s <br />Slst'zments must be used tOZ ail ODeramons <br />"-a Of Operarion: <br />.. T jrp <br />unless aDDZODL:ate 2LOnaie Or=eS=-.C.:.iOIIS are <br />provided) <br />S. Rei ease F-istory: <br />[ I Combustible Gas/Oxygen Me_e-- <br />vidence Of leaks/Soil connaminarion: [ I MS [ I NO <br />[ I Dete=or Tubes (Sbeci�) <br />Doc-=e=ed Groundwater contamination: ( ] ":S (J NO <br />[ J Photoionizat on Dere--or <br />Background and desc ipt on of any previous investigation <br />[ j Organic Vapor ?.naiyzer <br />or incidence: <br />[ j Other, speciry: <br />If monitoring ir==e= are sot •sed, <br />z:onale or acdvir-r /area res:coons: <br />5. Poce_ntial :ealt. and Safe --I <br />Physical Cance. --s: (check ad char apply & desc)e) <br />[ 1 rie3L or Cold Stress: °: (iiigh ambient re=p.) <br />[ I Noise Source: <br />2- Pe Soni P ore---ve : '=D=e= <br />(J Oxygen Dente=cy. <br />Level of Protection: [ IA [ JB [ IC [ ID <br />(]-cavadon: (fails, SDS ,Slipping cave-ins) <br />(] ::ard hat <br />[ I :.angling and master of a Hazardous Substance: <br />[ J Sa ery glasses/go&,es <br />(nee, espiosiors, enc.) <br />(J Steel coed/&: ank shoes or boots <br />[ ] Conned SOace enixy- (explosions) <br />[ j :name rerardanc coveralls <br />[ ] Heavy egmpmenr (physical injury & Sauina resulting <br />[ I Hearing prorec-on <br />from moving epuiipment) <br />[ I Tpvek <br />[ J Respirator, circle: APR or SC3A <br />( I Other, specify <br />A/A c ^dge: <br />(] Safety vest <br />i. ?mricipared Biologicmi 'razards: <br />[ j Two-way communication <br />j Snakes [ J Insects [ I Rodents [ j Poisonous Plants <br />(J Other/Unknown (specify): <br />PART X <br />PLAN APPROVAL <br />8. tiarraave (provide all information which could impact f^ealtn <br />and Saiery, e.g., power ices, inre;rr)r of d%Kes, ce^ain, etc): <br />Plan Prepared by. Dare: <br />Plan approved by. Dane: <br />_-'23081 (2/7/92) <br />