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SAN JOAQUIN COUNTY ENVIRON MENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART 11 <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: G4 i cry CF . 1. Chemicals Hazards <br /> Address: / 71oo S. lbk,41A, i Carcinogens: <br /> Contact Person::14 Phone No. 78Z �(Sir7 (] Corrosives: <br /> Sweeps Number. [ ] Dusts: <br /> Proposed Date of investigation/inspection: Explosives: <br /> 1;Wlammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> ( ] New UST Installation [] UAR Investigation 4,1 Metals: <br /> [ ] Tank Closure in Place ( ] Tank/Pipe Repair [ ] Oxidizers: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> Vjnstallario of Borings/Monitoring Wells <br /> " l+'w. '�^'A'orin AA PART III <br /> 3. Specific Site Information: AJf*_ 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/sort contamination: [ ] YES [ ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: ( ] YES ( ] NO ( ] Photoionizarion Detector <br /> Background and description of any previous investigation [J 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 /> eat or Cold Stress: �oF (high ambient temp.) <br /> [ ] oise Source: 2. Personal Protective Equipment <br /> [ J Oxygen Deficiency: Level of Protection: ( ]A [ ]B X-C 'PD <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) �J Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: {u�] Safety glasses/goggles <br /> (fire, explosions, etc.) ``] Steel toed/shank shoes or boors <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> ( ] Heavy equipment (physical injury&trauma resulting >{] Hearing protection <br /> from moving equipment) ] Tyvek <br /> (k],Respirator, circle: ® or SCBA <br /> [ j Other, specify A/P cartridge: (St46—i� <br /> ",(Safety vest <br /> 7. Anticipated Biological Hazards: [ 1-Two-way communication <br /> [ J Snakes [ J Insects ( ] Rodents ( ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART N <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: 7/ 9-5 <br /> Plan Approved by, Date: <br /> EH23081 (2/7/92) �� <br />