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i <br /> SAN JOAQUIN COtj.,-, I'Y ENVIRONMENTAL-REAL':IVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> 'ART I PART II <br /> 3ENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: S 1. Cligmicals Hazards <br /> Address: Carcinogens: <br /> Contact Person: Phone Nod ,Q)&Z X30,? [] Cprrosives: <br /> Sweeps Number: /0 — �— [ Dusts: <br /> Proposed Date of investigation/inspection: [ ] Explosives: <br /> [I Flammables: <br /> Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> I I New UST Installation [ I UAR Investigation [] Metals: <br /> [ ] ank Closure in Place [ I Tank/Pipe Repair [ J Oxidizers: <br /> [�Tank/Pipe Removal [ ] Re-excavation [)PCB's: <br /> [ ) Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: /O 000 EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> Type of Operation: unless appropriate rationale or restrictions are <br /> pro ' ed) <br /> Release History: ( Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: YES [ ] �jp [ I 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: [ I Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> b. Potential Health and Safety <br /> Physical Concerns: (check all that apply& describe) <br /> [ ] eat or Cold Stress: of (high ambient temp.) <br /> [t Noise Source: TA.z_-k. FarK 44 -- 2. Personal Protective Equipment <br /> [ ] 9xYgen Deficiency: Lene,L of Protection: ( ]A [ ]B [ IC [ )D <br /> [k'Ex�avation: (falls, trips ,slipping, cave-ins) [aI'Fjard hat <br /> [ andling and Transfer of a Hazardous Substance: [ afety glasses/goggles <br /> (fire, explosions, etc.) [ ] Steel toed/shank shoes or boots <br /> ( ] Cpnfined Space entry: (explosions) [ I F>me retardant coveralls <br /> (JITieavy equipment (physical injury & trauma resulting [LyHearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ) Respirator, circle: APR or SCBA <br /> ( ] Other, specify A/P cartridge: <br /> [ I Safety vest <br /> Anticipated Biological Hazards: [ I Two-way communication <br /> [ ) Snakes;. [ ] Insects [ I Rodents ( ] Poisonous Plants <br /> [ ) Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> Narrative (provide all information which could impact Health (/ <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by, � Dater— r) — <br /> �U VL BtJ _Cth-F.r . L a�u lila eiu/J,G <br /> TdxOZ ra4&S! y1d Plan Approved by: Date: �� <br /> 12 <br />