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SAN JOAQUIN COUNTY ENVIRONMEIENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site iName: �� � 1. Chemicals Hazards <br /> Address: [] Carcinogens: <br /> Contact Person: Phone No. �[,J Corrosives: <br /> Sweeps Number. 1CDusts: <br /> Proposed Date of investigarion/inspecrion: [ ] Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity. [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [J Metals: . <br /> ( ] Tank Closure in Place C Tank/Pipe Repair [] Oxidizers: <br /> [ ] Tank/Pipe Removal /�p� [ ]gR,e-excavation / []PCB's" <br /> FWell <br /> .jlh�gZoGt9�57� ( tiEfC (' PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> n instruments must be used for all operations <br /> 4. Type of Operation: 6—W-60 Ylq w4 -tld"'� unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History. [ J Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soIl contamination: [ ] YES [ ] NO [ J Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( ] NO [ ] Phoccionizarion Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: 1A2 i4Sr Other, specify: <br /> �Q PD/DAP �t wsv✓v p to 6W If monitoring instruments are not used, <br /> rationale or activity/area restri <br /> 6. Potential Health and Safety es S <br /> Physical Concerns: (check all char apply& describe) <br /> ( ] Hear or Cold Stress: of (high ambient temp.) <br /> Noise Source: �32 rn C'�CC j o_ v :n yr n ..0 2. Personal Protective Equipment <br /> [ ] C)xygen Deficien Level of Protection: [ ]A [ ]B [ ]C XD <br /> [vJ' n: alls, ains ,slipping cave-ins) Hard hat <br /> [ ] Handling and , azardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boors <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> Heavy equipment (physical injury& Qauma resulting Hearing protection <br /> from moving equipment) Fo e k [] Tyvek <br /> fdvz i.i gym, - [ ] Respirator, circle: APR or SCBA <br /> [ ] Offier, 1pecify A/P cartridge: <br /> >4Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ J Poisonous Plants <br /> [ J 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 duces, to etc.): Plan Prepared b Date: <br /> Plan Approved by Date: <br /> MZ <br /> E. 081 (2/7/92) <br />