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6 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATfION _` EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: V, Ja I[ 1. Chemicals azards <br /> Address: r cinogens: <br /> Contact Person: 'Phone o. `{• � rrosives: <br /> Sweeps Number: []Dusts:. <br /> Proposed Date of investigatio inspection: [] losives: <br /> [t�lammables: <br /> 2. Description and brief narrative of inspection activity: []I ganic 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 /> []YstalIapion of Borings/Monitoring Wells <br /> PART III <br /> 3.'Sp ific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment:(note:Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: pro mos D r unless appropriate rationale or restrictions are <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 /> [] t or Cold Stress: °F(high ambient temp.) <br /> oise Source: 2. Personal Protective Equipment <br /> []Oxygen Deficiency: Lev of Protection: []A []B []C <br /> []E vation: (falls,trips,slipping,cave-ins) [ rd hat <br /> andling and Transfer of a Hazardous Substance: S ty glasses/goggles <br /> (fire,explosions,etc.) tee toed/shank shoes or boots <br /> []Confined Space entry: (explosions) []F me retardant coveralls <br /> []Heavy equipment(physical injury&trauma resulting earing protection <br /> from moving equipment) []Tyvek <br /> [] <br /> Respppal6r,circle: APR or SCBA <br /> []Other,specify cartridge: <br /> [ Safety vest <br /> 7. Anticipated Biological Hazards: []Two-way communication <br /> []Snakes []Insects []Rodents []Poisonous Plants <br /> []Other/Unknown(specify): PART IV <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: - rk,. Date: �l[- <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />