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SAN JOAQUIN COUNTY EVVLRONMEN7AL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART lI <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: [] Carcinogens: <br /> Contact Person: Phone No. [I Corrosives: <br /> Sweeps Number: [I Dusts: <br /> Proposed Date of investigation/inspection: [I Explosives: <br /> [I Flammables: <br /> 2. Description and brief narrative of inspection activity: [I Inorganic Gases: <br /> [I New UST Installation [I UAR Investigation <br /> [I Metals: <br /> [I Tank Closure in Place (J Tank/Pipe Repair [I Oxidizers: <br /> [] Tank/Pipe Removal [] Re-excavation <br /> [I PCB's: <br /> [I Installation of Borings/Monitoring Wells <br /> PART [if <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 operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: [ j Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [I YES [I NO [j Detector Tubes (Specify) <br /> Documented Groundwater contamination: [I YES [I NO [j Photoionization Detector <br /> Background and description of any previous investigation [I Organic Vapor Analyzer <br /> or incidence: [ J 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 /> [I Heat or Cold Stress: °F (high ambient temp.) <br /> [I Noise Source: <br /> 2. Personal Protective Equipment <br /> [] Oxygen Deficiency: level of Protection: [IA [IB [IC [ID <br /> [] Excavation: (falls, trips ,slipping, cave-ins) [I Hard hat <br /> [] Handling and Transfer of a Hazardous Substance: [I Safety glasses/goggles <br /> (fire, explosions, etc.) <br /> [J Confined Space entry: (explosions) [I Steel toed/shank shoes or boots <br /> ( j Flame retardant coveralls <br /> [ ] Heavy equipment (physical injury & trauma resulting [I Hearing protection <br /> from moving equipment) [I Tyvek <br /> [] Other, specify [I Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> [I Safety vest <br /> 7. Anticipated Biological Hazards: [I Two-way communication <br /> [] Snakes [I Insects [I Rodents [] Poisonous Plants <br /> [j Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date: <br /> Plan Approved by: Date: <br /> EH23081 (7/7/92) <br />