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W%, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART IPART II <br /> GENERAL SITE INFORMATION s EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: SOW 1. Che icals Hazards <br /> Address: Che <br /> Contact Person: ' Phone No: U/ C rrosives: <br /> Sweeps Number: IJ 1Justs: <br /> Proposed Date of investigation/inspection: ❑E iosives: <br /> Flarn.,bles: <br /> 2. Description and brief narrative of inspection activity: [I Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> EV][,, tallation of Borings/Monitoring Wells. <br /> zardous waste inspection ❑ Sampling PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank No.: p ty' operations unless appropriate rationale or restrictions are provided) <br /> Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter. <br /> Other: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 4. Type of Operation:_,� ❑Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> 5. Release History: If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description o any previous investigation or incidence: <br /> C <br /> 2. Personal Protective Equipment �' <br /> Level of Protection: ❑A El F-1C I/J D <br /> ❑Hard Hat. <br /> 6. Potential Health and Safety ❑Safety Glasses/goggles, <br /> Physical Concerns:(check all that apply&describe) feel toed/shank shoes or boots. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) D Flame retardant coveralls. <br /> EjNoise Sources: 1 Hearing protection. <br /> ❑Oxygen Deficiency: ❑Tyvck. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Respirator: ❑APR ❑SCBA <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, A/P cartridge: <br /> etc..): <br /> ❑Safety vest. <br /> ❑Confined space entry:(explosions): fflfW,o_µ,ay communication. <br /> ETHeavy equipment(physical injury&trau resulting from moving <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL / <br /> Hazards: ✓`_ Date: ` <br /> 7. Anticipated Biological Ha Plan Prepared by: <br /> ❑Snakes Insects ❑Rodents ❑Poisonous Plants <br /> Other/Unknown(specify): Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(42/19/03) <br />