Laserfiche WebLink
SAN 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: 1. Chemicals Hazards <br /> Address: ZpO� i v a Nfi Carcinogens: <br /> Contact Person: ejk i Phone No. (] Corrosives: <br /> Sweeps Number. 3 r , pars; <br /> Proposed Date of investigation/inspection: _� Explosives: <br /> ammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [ ] Metals: <br /> [ <br /> 13,axfk Closure in Place ( ] Tank/Pipe Repair ( ] Oxidizers: <br /> Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Soecific Site I ormation: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. — Tank Capacity. �5D EQUIPMENT <br /> Tank Contents: f> 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 /> provi d) <br /> 5. Release HistoryCombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ( ] YES ( ] NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( ] NO <br /> C Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: ( J 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 /> ( ] Hea r Cold Stress: of (high ambient temp.) <br /> oue Source: 2. Personal Protective Equipment <br /> [ ]slxygen Deficiency: Level of Protection: ( ]A ( ]B A-JIf_,M <br /> Al Excavation: (falls, trips ,slipping, cave-ins) eM-Hard hat <br /> ( J Handling and Transfer of a Hazardous Substance: [-Safety glasses/goggles <br /> (fire, explosions, etc.) steel toed/shank shoes or boots <br /> [ ] Co ed Space entry. (explosions) [ ] Flame retardant coveralls <br /> eavy equipment (physical injury& trauma resulting A[]'Hearing protection <br /> from moving equipment) f y e <br /> ��] &espirator, circle: r SCBA <br /> [ ] Other, specify A/P cartridge: <br /> ( ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes ( ] Insects [ ] Rodents ( ] Poisonous Plant <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:/f�3 <br /> - <br /> PlanApproved by: _ Date!"(_ <br /> ER23081 (2/7/92) <br />