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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: [J Carcinogens: <br /> Contact Person: Phone No. [] Corrosives: <br /> Sweeps Number: [ ] Dusts: <br /> Proposed Date of investigation/inspection: ( ] Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ j New UST Installation [ I UAR Investigation [ J Metals: <br /> [ ] Tank Closure in Place [ j Tank/Pipe Repair [ ] Oxidizers: <br /> [ I Tank/Pipe Removal I ] Re-excavation [j PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( I YES [ j NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ J YES I I NO [ I Photoionization Detector <br /> Background and description of any previous investigation I] 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 /> [ I Heat or Cold Stress: of (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ )B I IC [ ]D <br /> [ ) Excavation: (falls, trips ,slipping, cave-ins) [ I Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, etc.) [ ) Steel toed/shank shoes or boots <br /> [ I Confined Space entry: (explosions) [ J Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ I Tyvek <br /> [ I Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ J Snakes; I I Insects I I Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <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 /> 12 <br />