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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> S= HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO TION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: l 1. Ch Gals Hazards <br /> Address: cinogens: <br /> Contact Person: , ► hone No. (, rrosives: <br /> Sweeps Numbe . [ ] Dusts: <br /> Proposed Date of investigation/inspection: [ Wlosives: <br /> lammables: <br /> 2. Description and brief narrative of inspection activity. [ J 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 /> vpoecuific <br /> tallation of Borings/Monitoring Wells <br /> PARion: REQT III <br /> UIRED PERSONAL PROTECTIVE <br /> 3. Site Information: <br /> Tank No. Tank Capacity. EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> s , instruments must be used for all operations <br /> OY 6�t unless appropriate rationale or restrictions are <br /> 4. Type of Operation: 4AI <br /> 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 [ ] 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: °F (high ambient temp.) <br /> [��se 2.Source: Personal Protective Equipment <br /> [ ] Oxygen Deficiency Levfi,of Protection: [ ]A [ ]B [ ]C <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) d hat <br /> [�dling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) (Leel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) PeMg <br /> retardant coveralls <br /> [ ] Heavy equipment (physical injury& trauma resulting protection <br /> from moving equipment) [ ] TYve-k <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/&cartridge: <br /> �Sety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes ( ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART N <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. {moi Date:'• - <br /> Plan Approved by. ate: �l !bD <br /> EH23081 (2/7/92) <br />