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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART H <br /> PART ION OF POTENTIAL HAZARDS <br /> GENERAL SITE INFORMATION <br /> 1. Site Name: <br /> Address: 1. Chemicals Hazards <br /> �• U v� t [] Carcinogens: <br /> Contact Person: PG Phone No. ]!t -6175 [] Corrosives: <br /> Sweeps Number. 1 22 / f7 E <br /> �] xplosives: <br /> Proposed Date ofinvestigadon/inspection: QI Explosives- <br /> Proposed <br /> [>] Flarmnables: <br /> 2. Description and brief narrative of inspection activity. [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation ]Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> [�Tank�Rem- ov [ ] Re-excavation [l PCB's: <br /> [ ] Installation of Borings/Monitoring Wells PART III <br /> 3. Specific Site Info ation: REQUIRED PERSONAL PROTECITVE <br /> Tank No. I�rRljX 040Tank Capacity: EQUIPMENT <br /> Tank Contents: ggi Tank Age: cam. K. <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: e-M SCJ LEZ]a unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History. '{ Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ I YES [ I 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 /> {<],Heat or Cold Stress: of (high ambient temp.) <br /> k Noise Source: 2. Personal Protective Equipment <br /> [ ] xygen Deficiency: L vel of Protection: [ ]A [ ]B {fC KD <br /> {acExcavation: (falls, trips ,slipping, cave-ins) Hard at <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> T11.Heavy equipment (physical injury & trauma resulting ]W Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> Respirator, circle: (Por SCBA <br /> [ ] Other, specify A/P cartridge: <br /> ( ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> ' Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plant <br /> [ ] Other/Unknown (specify): PART N <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 /" Date- <br /> Plan Approved by _ Date: <br /> 1'r <br /> EH23081 (2/7/92) <br />