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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: S1'V't'o c—� 1. Chemicals Hazards <br /> Address: Lt M I--- #1 n� <br /> Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection: <br /> ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 4 Hazardous waste inspection ❑ Sampling PART IH <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other. ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation: (Al 1't_� NA./-'It"F� �a���' ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C <br /> 6. Potential Health and Safety ZHard Hat. ////���� <br /> Physical Concerns:(check all that apply&describe)gh Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: F i ambient <br /> (h gyp) Steel toed/shank shoes or boots. <br /> Noise Sources: <br /> El Flame retardant coveralls. <br /> Hearing protection. <br /> ❑Oxygen Deficiency: <br /> excavation:(falls,trips,slipping,cave-ins): El[IRRespirator: El APR ❑SCBA <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> cartridge: <br /> etc..): <br /> El Confined space entry:(explosions): Safety vest. <br /> ZHeavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> Plan Prepared by: K/(, Date: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by: Date: v C- <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (02/19/03) <br />