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SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: Cz��+%ne }- ( Lp�GV ISIG� 1. Chemicals Hazards <br /> Address: ( ¢res Q,r,� C), -*A0n*_cr a (etarcinogens: <br /> Contact Person: Phone No. C Corrosives: <br /> Sweeps Number. [eDusts: T-Y co-V0.( to So l <br /> Proposed Dare of investigation/inspection: [ ] Explosives: <br /> [vJ'l:lammables: C�-as <br /> 2. Description and brief narrative of inspection activity: ( ] inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers- <br /> [vrTa_nk/Pipe Removal ( ] Re-excavation []PCB's- <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity-. /F C`Cpn EQUIPMENT <br /> Tank Contents: UT &ra_S Tank Age: 17 r <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: ( ] YES ( J NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: ( ] YES ( ] NO [ ] Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: A" ] Other, specify: <br /> no- crl. 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 /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C EtlD <br /> [ yFxcavation: (falls, trips ,slipping, cave-ins) } [ YHazd hat <br /> [vr Handling and Transfer of a Hazardous Substa$ce• [r]'Safery glasses/goggles <br /> (fire, explosions, etc.) H"!' teel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br /> [yJ Heavy equipment (physical injury& trauma resulting LJ-Hearing protection <br /> from moving equipment) ] Tyvek <br /> ( <br /> ] Respirator, circle: APR or SCBA <br /> ] Other, specify ( A/P cartridge: <br /> g - <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> ( ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and d SC�ty, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by Date: �-�Q-c}S <br /> £xco xc�#toh i (' yv hcac� <br /> V e h c 1 Tro Plan Approved by: Date: <br /> EH23081 (2/7/92) • • <br />