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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEAL'T'H AND SAFETY PLAN <br /> PART PART R <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> / <br /> 1. Site Name: ( \ .) 1(o., �. S. 1. Chemicals Hazards <br /> Address: y S £_ <r ins [] Carcinogens: <br /> Contact Person: Phone No.S)o y 4I z 1 fr `/ []Corrosives: <br /> Sweeps Number. 1 1 35- [ ] amu. <br /> Proposed Date of investigation/inspection: 3- Ids-S y [ J Explosives: <br /> H-V(ammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ I New UST Installation [ J UAR Investigation [ I Metals: <br /> [ ] Tank Closure in Place [ J Tank/Pipe Repair [ ] Oxidizers: <br /> [,1,Taank/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. 11 38 Tank Capacity: EQUIPMENT <br /> Tank Contents: T„<i Tank Age: Q� �_ <br /> Other. 1. Monitoring Equipment: (note: Monitoring <br /> \ instruments must be used for all operations <br /> 4. Type of Operation: (,os C)-1 unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( I YES P-90 0 [ I De3ector Tubes (Specify) <br /> Documented Groundwater contamination: [,r'SES [ ;;-40 CrPhotoionization Detector <br /> Background and description of any previous investigation [I Organic Vapor Analyzer <br /> or incidence: S i 1 A L-0 P �Lros�a [ ] 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 /> [ ] Noise Source: 2. Personal Protective Equipment / <br /> [ ] Oxygen Deficiency. LeLevelof Protection: [ ]A [ ]B [ IC [�i3 <br /> [4-Excavation: (falls, trips ,slipping, cave-ins) [4- and hat <br /> [ I Handling and Transfer of a Hazardous Substance: [ I S ety glasses/goggles <br /> (fire, explosions, etc.) [ Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ I Flame retardant coveralls <br /> [,3-Heavy equipment (physical injury & trauma resulting [ I Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ I Respirator, circle: APR or SCBA <br /> [ I Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ I Two-way communication <br /> [ ] Snakes [ J Insects [ I Rodents [ I Poi�so7nous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health �jfQ <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date:r�y S <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />