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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 />1. Site Name: 6nezy',( %tD <br />1. 'cals Hazards <br />Address: ��C� C_ <br />(h <br />cnogens: �y�s1E <br />Contact Peon: Macx Dr r Phone No. 52d" <br />[ ] Colrosives: <br />Sweeps Number. <br />r <br />(justs: <br />Proposed Date of investigation/inspecrion: <br />[ ] FPlosives: <br />[ lammables: Q'ESEL <br />2. Description and brief narrative of inspection activity: <br />[ ] Inorganic Gases: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Metals: <br />[ ] T,4nk Closure in Place [ ] Tank/Pipe Repair <br />(] Oxidizers: <br />[ ank/Pipe Removal [ J Re -excavation <br />[ ] PCB's: <br />[ ] Installation of Borings/Monitoring Wells <br />PART III <br />3. Specific Sire Information: <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. Tank Capacity: LZ,,&nn <br />Tank Contents: o Tank Age: my _ <br />EQUIPMENT <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />4. Type of Operation: 7-72,y�,,4 17,+—,12unless <br />appropriate rationale or restrictions are <br />provt <br />5. Release History <br />pmbusrible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: [ ] YES [r IO <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES ( 1 O <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 nor used, <br />rationale or activity /area restrictions: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Hear or Cold Stress: °F (high ambient temp.) <br />[iI' oise Source: <br />[ ] Oxygen Deflcien <br />2. Personal Protective Equipment / <br />Level Protection: CIA (]B CIC j }H' <br />[4'Excavadon: (falls, trips ,slipping, cave-ins) <br />[hat <br />L*"Sandling and Transfer of a Hazardous Substance: <br />[ aferyglasses/goggles <br />(fire, explosions, etc.) <br />[�teel toed/shank shoes or boots <br />[ ] Confined Space entry. (explosions) <br />[ ] Flame retardant coveralls <br />PT'Peavy equipment (physical injury & trauma resulting <br />[ ] Hearing protection <br />from moving equipment) <br />[ ] Tyek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] Other, specify <br />A/P cartridge: <br />( ] Safety vesr <br />7. Anticipated BiolWfcal Hazar <br />[ ] Two-way communication <br />[ ] Snakes Insects [4 -Rodents (] Poisonous Plants <br />[ ] Other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />S. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />n/��/ <br />Plan Prepared by. Z& Date: 47 <br />Plan Approved by: CLI Date: <br />EH23081 (2/7/92) <br />