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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 1 / EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: csfoc• ` 2/y "SA? 1. Chemicals Hazards <br /> Address: O E. L � azcinogens: bonnn P� a <br /> Contact Person: 7"a IN . U.RrU O Phone No. [] orrosives: <br /> Sweeps Number. / S8 I Dusts: <br /> Proposed Date of investigation/inspection: /vI Explosives: <br /> lammables: <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/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.-0 /I of 3' - Tank Capacity:'3Ooo— /q000 EQUIPMENT <br /> Tank Contents- pcd aypTank Age: -0'A0 , <br /> Other: �' 1. Monitoring Equipment: (note: Monitoring <br /> pp instruments must be used for all operations <br /> 4. Type of Operation: S _7 2X•-jS end t/ unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( ] YES [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES O [ J Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: .e ow [ ] Other, specify: <br /> ( -r c- 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: �� �oof (high ambient temp.) <br /> Noise Source: b a2 G K / �i 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C D(D <br /> ,,>"qxcavadon: (falls, trips ,slipping, cave-ins) , <Hard hat <br /> j{andling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) KSteel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> Heavy equipment (physical injury& trauma resulting $]_Hearing protection <br /> from moving equipment) [ I Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> �Safery vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): A](j Ile, PART IV <br /> PIAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integre of dikes, terrain, etc.): Plan Prepared by: ate: <br /> No !2AP <br /> Plan Approved by: k0tkZtDate: <br /> EH23081 (2/7/92) <br />