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r a <br /> SALT JOAQUIN COUNTY M VIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART B <br /> GENERAL SITE 24FORMAnON//�� EVALUATION OF POTENTIAL HA7.ARDS <br /> 1. Site Name- kv ` w/ 1. Ch 'call Hazards <br /> Address. �T�m Ln <._ g: :� oSens: i11?. J1AF. <br /> Contact Person: Phone No. [ =-- <br /> Sweeps Number. <br /> Proposed Date of investigation/inspecuon: [ jElosives: <br /> [x'Flammables• UGrEL <br /> 2. Description and brief narrative of inspection activity: [I Inorganic Gases: <br /> ( I New UST Installation [I UAFL Investigation [I Metals.. <br /> [ I�Closure in Place [] Tank/Pipe Repair [I Oxidizers: <br /> [ ank/Pipe Removal [I R&4xcavation [I PCB's: <br /> (I Installation of Borings/Monkoring wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL.PROTECTIVE <br /> Tank No._ mA <br /> �Tank Capacity. i z, EQUIPMENT <br /> Tank Contents: 0%w.L Tank Age: Gw,k — <br /> Other. 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operarions <br /> 4. Type of Operation: —1J?A0 C.,4 Sri-®.o unless appropriate rationale or rest salons are <br /> Provi <br /> S. Release History: Roninbusable Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ I YES [rj'F10 [I Detector Tubes (Specify) <br /> Documented Groundwater contamination:-1.I YES [ i0 [I Photoicnization Detector <br /> Background and description of any previous investigation [I Organic Vapor Analyzer <br /> or incidence: [I Other, specify. <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> b. Potential Health and Safety <br /> Physical Concerns: (check all that apply&describe) <br /> [ I Heat or Cold Stress: OF (high ambient temp.) <br /> oise Source: t—MAf4- 2 Personal Protective Equipment <br /> [ lOxyVm Dedcien Level Protection: (]A []B [IC <br /> [-?facavadon: (falls, trips ,slipping, cave-ins) [ITI hat <br /> [,lRandling and Transfer of a Hazardous Substance: [ ety glasses/goggles <br /> (fire, explosions, em) [44teel toed/shank shoes.or boots <br /> [I Confined Space entry: (explosions) [I Flame retardant coveralls <br /> K fieavy equipment(physical injury&trauma resulting [I Hearing protection <br /> from moving equipment) [I Tye <br /> (I Respirator, circle: APR or SCBA <br /> [I other, specify A/P cartridge: <br /> [] Safety vest <br /> 7. Anticipated Bio1qgfW [I Two-way communication <br /> ( I Snakes Klnsecrs [40Pode= [I Poisonous Plants <br /> [ I Other/Unknown (specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health �,`n' <br /> and Safety, e.g., power Lines, integrity of dikes, terrain, etc.): Pian Prepared by: Date: <br /> Plan Approved by.�u Date: <br /> MH0081 (2/7/92) <br />