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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />?.ART I PART H <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL. HAZARDS <br />1. Site Name: <br />Address: t0jl <br />Contact Person: R. bolui Phone Nobs -367.9330 <br />Sweeps Number. / <br />Proposed Date of investigarion/inspection: <br />2. Description and brief narrative of inspection activity. <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [ J Tank/Pipe Repair <br />Tank/Pipe Removal [ ] Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />3. Specific Site Information: <br />Tank No. Tank Capacity: 12 K <br />Tank Contents: Gi¢-SoGi /u C Tank Age: <br />Other: <br />4. Type of Operation: � 3T74T70W <br />12--l- <br />4. <br />Lt <br />S. Release History. <br />Evider_ce of leaks/soil contamination: [vj��ES (] NO <br />Documented Groundwater contamination: Cit [ ] NO <br />Background and description of any previous investigation <br />or incidence: <br />/-k <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />( ] ' eat or Cold Stress: of (high ambienr temp.) <br />[(Noise Source: E <br />[ ] xygen Denciency <br />[excavation: (falls, trips ,slipping, cave-ins) <br />[ ] Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry. (explosions) <br />[Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />Other, specify <br />Anticipated Biological Hazards: <br />[ ] Snakes [ ] Insects [ ] Rodents <br />[ ] Other/Unknown (specify): <br />[ ] Poisonous Plants <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., oower lines, integrity o dikes, terrain, etc.): <br />-1- 3081 (2/7/92) <br />Chemicals Hazard <br />[ Cazcinogens:ens: <br />[ ] Corrosives: <br />[ ] Dusts: <br />[ ] Pxplosives: <br />( Flammables: Q—x ti►� O S <br />[ ] Inorganic Gases: <br />[ ] Metals: <br />[ ] Oxidizers: <br />(] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />pro ded) <br />(combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ ] Organic Vapor Analyzer <br />[ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: [ ]A [ ]B [ ]C [✓jD <br />C -T -Hard hat <br />[-�'$afety glasses/goggles <br />[_�_S teel toed/shank shoes or boors <br />[ ] Flame retardant coveralls <br />(Hearing protection <br />[ ] Tyve-k <br />[,J'Respirator, circle: APR r SCBA <br />[4P cartridge: w <br />S ery vest <br />(] Two-way communicarion <br />PART N <br />PLAN APPROVAL <br />Plan Prepared by: -r Date: <br />Plan Approved by: Date: <br />