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SAN JOAQUIN CC7"UNTY ENVIRONMENTAL HEALOT DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> SRT I PART II <br /> kRT I SITE INFORMATION( EVALUATION OF POTENTIAL. HAZARDS <br /> Site Name: Vbr+ D Y 1. Ch tcals Hazards <br /> Address: 22[ l .�a v 11 a � [ Carcinogens: <br /> Contact Person: Pli <br /> one No. - 14(o (J Corrosives: <br /> [ ] ftisu: <br /> Sweeps Number: 1 Z. <br /> Proposed Date of investigation/inspection: urnfL [,yFlammables: <br /> 7escription and brief narrative of inspection activity: I ] Inorganic Gases: <br /> [ J New UST Installation [ ) UAR Investigation [ ] Metals: <br /> [ ) k Closure in Place [ ] Tank/Pipe Repair ( ] Oxidizers: <br /> [ ank/Pipe Removal [ ] Re-excavation [] PCB's: <br /> [ ] Installation of Borings/Monitoring Wells PART III <br /> 3. Specific Site Inf�/�tn�ation:REQUIRED PERSONAL PROTECTIVE <br /> Tank No. �— Tank Capacity: 2 0-6D EQUIPMENT <br /> Tank Contents: P, Tank Age: wn�— <br /> other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: �OY unless appropriate rationale or restrictions are <br /> pro <br /> S. Release History: -f �� <br /> wk ( Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: 0 ( E ( ) NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination- [ [ J NO L ] Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ ) Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 5. Potential Health and Safety <br /> Phy 'cal Concerns: (check all that apply & describe) <br /> [ Heat or Cold Stress: of (high ambient temp.) 2 personal Protective Equipment <br /> [ ] Noise Source: <br /> [ J gen Deficiency: Leve Protection: [ ]A [ lB [ ]C [ <br /> ( xcavation: (falls, trips ,slipping, cave-ins) [ 'wand hat <br /> (�ndling and Transfer of a Hazardous Substance: [y-;a glasses/goggles <br /> (fire, explosions, etc.) ( teel toed/shank shoes or boots <br /> [ J Copfined Space entry: (explosions) [ ) Flame retardant coveralls <br /> [J,,Keavy equipment (physical injury& trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ) Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> I J Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ J Snakes; ( ] Insects [ ] Rodents [ ] Poisonous Plants PART N <br /> [ ] Other/Unknown (specify): PLAN APPROVAL <br /> ti. Narrative (provide all information which could impact Health' <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date: <br /> Plan Approved by: Date: cl <br /> 12 <br />