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SAN JOAQUIi I COUNTY EWIROi\�ti�AL HEALTH- DIVISION <br /> SITE H EAL 7zI AND SAFETY PL-\i <br /> PART I PART II <br /> G NE.RA_ L SITE INFORMATION EVALUATION OF POT—ENT1AL HAZARDS <br /> 1. Site Name:, CV11,R1 ',11,_�'!�_P T. t i l C '�!' l.l�'1 rD 1. Chemicals Hazards <br /> Address: ,-;i. It / (I Carcinogens: <br /> Contact Person: G 41 Jd hone No. r" . �Q 4- [] Corrosives: <br /> Sweeps Number: 61 0 r usrs: <br /> Proposed Date of investigarion/inspecrion: f'�J- ( I Explosives: <br /> [I r'lammables: <br /> 2. Desciprion and brief narrative of inspection acrivity: [ I [norganic Cases: <br /> [ I New UST Installation [ ] UAR Investigation XMetais: <br /> ( I Tank Closure in Place ( ] Tank/Pipe Repair (j Oxidizers: <br /> ( ] Tank/Pipe Removal ( ] Re-excavation [I PC3's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> L,J"HAL,)A-S t�' , PART M <br /> 3. Soecii:c Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIP*i1ENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Ylonirorng Equipment (note: Monitoring <br /> i==-.mens must be used for all operations <br /> 4. Type of Operation: CA, k-LAc-) ' unless appropriate rationale orresrricrions are <br /> p r& c C'.�>��>i� ;-" v` �'�'`��l/ ,1, provided) <br /> S. Release Fdstory: [ I Combustinle Gas/Oxygen vlerer <br /> 7-vidence of leaks/soil contamination: [ ] YES C NO [ I Cerecror Tubes (Soecify) <br /> Documented Groundwater contamination: f, ] = [ I NO [ I Photoionization Detector <br /> Back-round and description of any previous investiganon [I Organic Vapor Analyzer <br /> or incidence: 9, Y [ ] Offer, specify- <br /> - �'~ If Womroring instruments are not used, <br /> c' - rationale or activity/area resnictions: <br /> 6. Potential Health and Safety <br /> Physical Conce*ns: (check ail that aDDly& descrfoe) <br /> [ ] meat or Cold Stress: °r (high ambient temp.) <br /> Noise Source: 2 Personal Protective Equipment <br /> ( j Oxygen Deficiency- Level of Protection: [ ?A [ ]B [ IC �D <br /> 7 a Cfatts, Gips ,slipaing, cave-ins) �.ard Tzar ` <br /> /C j Handling and Transfer of a Hazardous Substance: XSarety glasses/goggles <br /> (fire, explosions, etc) XSteell coed/shank shoes or boars <br /> [ j Connned Soace entry: (explosions) [ j dame retardant coveralls <br /> [ I Heavy equipment (physical injury& c auma resulting [ I Hearing protection <br /> from moving equipmenr) [ I Tyvek <br /> ( I Respirator, circle: APF or SC3A <br /> [ I Other, specify AN. c3rr-idge- r=�t• is lir.X11 Y! <br /> / ( ] Safety vest <br /> 7. Anricoared Biological Hazards: IVO YU E E=X feG-fP ( I Two-way communication <br /> I Snakes [ I Insects [ I Rodents ( I Poisonous Plants <br /> [ ] othe--/Unknown (specify): PART rV <br /> PIAN APPROVAL ., <br /> I Narrative (provide all information which could impact Health %; fit <br /> r �3� <br /> anIAJ'd/1SafFty, e.cr, power Tines, integrity of dikes, ce-*rain, etc):Y Plan Prepared by.- <' Dare: <br /> Plan Approved by. Dareep-9/ i-6 <br /> E:-i23081 (2/7/92) <br />