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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />t� <br />1. Site Name: Te �fS d I YL - t <br />1. Chemical Hazards <br />Carcinogens: <br />Address: <br />[v] <br />Contact Person:i Phone No. <br />[corrosives: <br />Sweeps Number: <br />(] Dusts: <br />Proposed Date of investigation/inspection: <br />[ ] Explosives: <br />VFlanunables: <br />2. Description and brief narrative of inspection activity: <br />[ ] Inorganic Gases: <br />[ ] New UST Installation [ ] UAR Investigation <br />HIvtetals: <br />[ ] Tank Closure in Place (] Tank/Pipe Repair <br />[ ] Oxidizers: -- <br />[ ] Tank/Pipe Removal [ J Re -excavation <br />[ ] PCB's: <br />[ ] tallation of Borings/Monitoring Wells <br />irene.rAfP r <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />3. Specific Site Infomiation: <br />Tank No. Tank Capacity: <br />EQUIPMENT <br />Tank Contents: Tank Age: <br />1. Monitoring Equipment: (note: Monitoring <br />Other: <br />instruments must be used for all operations <br />11 (j� <br />4. Type of Operation: L30�1 &I VIGI <br />unless appropriate rationale or restrictions are <br />provided) <br />5. Release History: <br />[ ] Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />[ ] Photoionization Detector <br />Background and description of any previous investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: <br />[ ] 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: OF (high ambient temp.) <br />2. Personal Protective Equipment / <br />[ ] Noise Source: <br />[ ] Oxygen Deficiency: <br />Level of Protection: [ ]A [ ]B [ ]C KD <br />[+I hard hat <br />(] Excavation: (falls, trips ,slipping, cave-ins) <br />f4tafety glasses/goggles <br />,(Handling and Transfer of a Hazardous Substance: <br />[Steel toed/shank shoes or boots <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />[ ] Flame retardant coveralls <br />[ ] Heavy equipment (physical injury & trauma resulting <br />(earing protection <br />from moving equipment) <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] Other, specify <br />A/P cartridge: <br />[+Kafety vest <br />7. Anticipated Biological Hazards: <br />[ ] Two-way communication <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ ] other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />S. Narrative (provide all infomiation which could impact Health[.L, <br />Plan Prepared by: Ur1ltDate: 1 DU <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Approved by:0� / Date: <br />EH23081 (2/7/92) <br />