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SAM JOAQUIN COUNTY ENVIRONMENTAL HEALrrI DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> 'ART I PART II <br /> .,NERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> Site Name: G v/� /,QN�/0//✓G 1. Chemicals Hazards <br /> Address: S'[t,��,�/� G y`J�'fi�/[] Carcinogens: <br /> Contact Person: Phone No. /C� [] Corrosives: <br /> Sweeps Number: / 7 ti [ ) Dusts: <br /> Proposed Date of investigation/inspection: [ ] Explosives: <br /> [ ] Flammables: <br /> Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation ( ] UAR Investigation [ ) Metals: <br /> ( J Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> Pd Tank/Pipe Removal [ ] Re-excavation [] PCB's: <br /> [ ) Installation of Borings/Monitoring Wells PART III <br /> :. <br /> Specific Site Information: 3� REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: � EQUIPMENT <br /> Tank Contents: d1 G L Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> t. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ ] YES ( ] NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ J NO [ ] 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 /> i. 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 [ ]D <br /> ( J Excavation: (falls, trips ,slipping, cave-ins) [ ] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ ] Safety glasses/goggles <br /> (fire, explosions, etc.) [ ] Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ J 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 /> ( j 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 Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date: <br /> Plan Approved by: Date: <br /> 12 <br />