Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONiMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN1 <br /> L�(�� ILILi�`TIF�L <br /> PART I PART II <br /> BNSITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: �i c � <br /> 1. C micals Hazards <br /> Address: �3 ��Q �- 5=� � �� ��" [ACarcinogens: <br /> Contact Person: Phone No. 'y2-&6±-3�fv (] C99�rosives: <br /> Sweeps Number. %- [4•busu: <br /> Proposed Date of investigation/inspection: [ 1171am able <br /> [�I Flammables: <br /> Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New T Installation [ ] UAR Investigation [] Metals: <br /> [ ] <br /> T#Ak Closure in Place ( ] Tank/Pipe Repair [ ] Oxidizers: <br /> [LI-Tank/Pipe Removal [ ] Re-excavation [] PCB's: <br /> ( ] Installation of Borings/Monitoring Wells <br /> PART III <br /> Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. f; Tank Capacity: /d(u(�'E.cj EQUIPMENT <br /> Tank Contents: ✓' LL,-U,4,60 Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ins avm must be used for all operations <br /> Type of Operation: G)GLJ _k unless pru opriate rationale or restrictions are <br /> pro ' ed) <br /> Release History- [ ombusdble Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES [y 1y0 ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ I YES [ NO [ ] oiz tion Detector <br /> Or <br /> Background and description of any previous investigation [] Organic PAnalyzer <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 /> [ j Noise Source: 2. Personal Protective Equipment y' <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A ( ]B [ ]C [-ID <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) [ ] Hard hat <br /> [:�Ia dling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> re-explosions, etc.) [ ] Steel toed/shank shoes or boots <br /> [ nfined Space entry: (explosions) [ ] Flame retardant coveralls <br /> ( eavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) ( ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> Anticipated Biological Hazards: ( ] Two-way communication <br /> ( ] Snakes; [ ] Insects [ ] Rodents [ ] Poisonous Plants PART IV <br /> [ ] Other/Unknown (specify): <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 5 G ; Date: <br /> Plan Approved by: Date: <br /> 12 ��A-J <br />