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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL 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: L . 1. Ch cals Hazards <br /> Address: v Carcinogens: <br /> Contact Person: Phone No. �3 [] Corrosives: <br /> Sweeps Number. [ ] D <br /> Proposed Date of investigation/inspection: [ osives: <br /> [• ammables <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ j New UST Installation [ ] UAR Investigation [ ] Metals: <br /> ( ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> [$I-Fank/Pipe Removal [ ] Re-excavation [ CB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity "3 J(&' OJO EQUIPMENT <br /> Tank Contents: Vy 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 /> pro ' ed) <br /> 5. Release History. / [ Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: I ] YES [v] IJA [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( O [ ] 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 /> 6. Potential Health and Safety <br /> Ph Concerns: (check all that apply& describe) <br /> [THPat or Cold Stress: of (high ambient temp.) <br /> [ oise Source: 2 Personal Protective Equipment / <br /> [ ] gen Deficiency Lev of Protection [ ]A [ ]B [ ]C [tib <br /> [ Excavation: (falls, trips ,slipping, cave-ins) �T jard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: VYS*ty glasses/goggles <br /> (fire, explosions, etc.) [ Steel toed/shank shoes or boots <br /> [ ] filmed Space entry: (explosions) [ ] Flame retardant coveralls <br /> [ Heavy equipment (physical injury& trauma resulting [+'Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> ( ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ ] Other/Unknown (specify): PARTFV <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: <br /> _T PlanApproved by: 10J_4_J Date: <br /> EH23081 (2/7/92) <br />