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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION �f EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: z�� '- 3�(G_ ! 1. Chemicals Hazards <br /> Address: ;_-46y� Carcinogens: <br /> Contact Person: Phone No. [] Corrosives: <br /> Sweeps Number: 4 9'_ ' [ ] Dusts: <br /> Proposed Date of investigation/inspection: O]-Explosives: <br /> 3�Z Flammables: <br /> 2. Descriptnox�and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [[] ew_lJT8T Installation [ ] UAR Investigation [ ] Metals: <br /> ] rTank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> �Tank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> h <br /> PART III "- <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operation <br /> 4. Type of Operation: unless appropriate rationale or restriction <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 [ ] 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 /> 6. 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 A_>Z [ <br /> Excavation: (falls, trips ,slipping, cave-ins) and 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 /> om moving equipment) ] Tyvek <br /> 't�j Respirator, circle: (Pi� 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): 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: A — Dater <br /> EH23081 (2/7/92) <br /> 1 <br />