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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART 11 <br /> PART l EVALUATION OF POTENTIAL HAZARDS <br /> ENERAL SITE INFORMATION <br /> 1. Chemicals Hazards <br /> 1. Site Name: [] Carcinogens: <br /> Address: -------Phone [] Corrosives: <br /> Contact Person:_ No. <br /> [ ] Dusts• <br /> Sweeps Number. [ ] Explosives: <br /> Proposed Date of investigation/inspection: [] Flammables: <br /> [ ] Inorganic Gases: <br /> Description and brief narrative of inspection activity Metals: <br /> [ ] New UST Installation [ ] UAR Investigation [ J <br /> Tank/Pipe a Re air [ ) Oxidizers: <br /> [ ] Tank Closure in Place ( ] P p [j PCB's: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation <br /> [ ] installation of Borings/Monitoring Wells PART III <br /> REQUIRED PERSONAL PROTECTIVE <br /> Specific Site Information: EQUIPMENT <br /> Tank No. Tank Capacity: <br /> Tank Contents: Tank Age: <br /> 1. Monitoring Equipment: (note: Monitoring <br /> Other: instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> 4. Type of Operation: provided) <br /> [ I Combustible Gas/Oxygen Meter <br /> S. Release History: NO [ ] Detector Tubes (Specify)_ <br /> Evidence of leaks/soil contamination: [ 1 YES [ ] photoionization Detector <br /> Documented Groundwater contamination: [ I YES [ l NO [ J Organic Vapor Analyzer�— <br /> Background and description of any previous investigation other, specify: <br /> or incidence: 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 /> 2. Personal Protective Equipment <br /> [ ] Noise Source: Level of Protection: [ ]A [ ]B [ ]C [ ID <br /> ( ] Oxygen Deficiency: [ I Hard hat <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) Safeglasses/goggles <br /> ( J Handling and Transfer of a Hazardous Substance: I ] Steel ank or boots <br /> (fire, explosions, etc.) ( ] Flame retardant coveralls <br /> [ ] Confined Space entry: (explosions)— protection <br /> [ J Heavy equipment (physical injury & trauma resulting I ] HeariHearin g P <br /> Tyvek <br /> from moving equipment) I ] Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> [ J Other, specify [ ] Safety vest <br /> 7. Anticipated Biological Hazards: <br /> [ J Two-way communication <br /> [ ] Snakes; [ ] Insects [ ] Rodents [ ] Poisonous Plants PART IV <br /> [ ] Other/Unknown (specify): PIAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health Date: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: <br /> Plan Approved by: Date: <br /> 12 <br />