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SAIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SrM HEALTH AND SAFETY PLAN <br />?ART I PART II <br />GENERAL SPIE INFORMATION EVALUATION OF POE 'IIAL HAZARDS <br />1. Site Name <br />Address: <br />Contact Person: hone No. —' Soo <br />Sweeps Number. <br />Proposed Date of investigation/inspection: —Q, 7 — <br />Description and brief narrative of inspection activity- <br />(] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ ] Tank/Pipe Removal [ ] Re -excavation <br />[ ],Installation of Borings/Monitoring Wells <br />Specific Site Information: /V <br />Tank No. Tank Capacity. <br />Tank Contents: Tank Age: <br />Other: <br />?. Type of Operation: MP <br />S. Release History - <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />Dccumented Groundwater cor-tamLriation: [ 1 YES [ ] NO <br />Background and description of arevious ,investigation <br />or incidence: <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: <br />[ J Oxygen Deficiency: <br />[ ] Excavation: (falls, trips ,slipping, cave-ins) <br />[ ] Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />`'Heavy equipment (physical injury & trauma resulting <br />`from moving equipment) jYi F - y. <br />Other, specify <br />7. Anticipated Biological Hazards: 04 <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and ety e.g., power lines, integrity of dikes, terrain, etc.): <br />EH23081 (2/7/92) <br />Chemicals Hazards <br />[] Carcinogens: _ <br />[ ] Corrosives: <br />K Dusts: <br />[] Explosives: <br />[ ] Flammables: _ <br />[ ] Inorganic Gases: <br />Metals: <br />] <br />Oxidizers: <br />[ ] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) . <br />[ ] Combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ ] Organic Vapor Analyzer <br />[ J Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2 Personal Protective Equipment <br />Level of Protection: [ ]A [ ]BC �D <br />Hard hat <br />Safety glasses/goggles <br />{ ] Steel toed/shank shoes or boots <br />[ J Flame retardant coveralls <br />Hearing protection <br />[ ] Tyvek <br />X -Respirator, circle: � or SCBA <br />A/P cartridge: <br />[ ] Safety vest 19 <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared bsdi Date: 4�'-a7 <br />Plan Approved by.i__11:5_�� Dat��j` <br />