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SAN JOAQLTR t COUNTY 2gVaONl1 7AL jEA,TH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART 11 <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: <br /> [] Carcinogens: <br /> Contact Person: <br /> Phone No. [I Corrosives: <br /> Sweeps Number: [I Dusts: <br /> Proposed Date of investigation/inspection: [J Explosives: <br /> 2. Description and brief narrative of Inspection activity: [I F organa les: <br /> p tY' [I Inorganic Gases: <br /> [] New UST Installation [J UAR Investigation [] Metals: <br /> [I Tank Closure in Place (J Tank/Pipe Repair <br /> [ (] Oxidizers: <br /> I Tank/Pipe Removal <br /> [I Re-excavation [I Pca's: <br /> [I Installation of Borings/Monitoring Wells <br /> 3. Specific Site Information: PART IIIREQUIRED 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 /> 5. Release History: provided) <br /> Evidence of leaks/soil contamination: [] YES [] NO [ I Combustible Gas/Oxygen Meter <br /> Documented Groundwater contamination: [] YES [j ,NO [I Detector Tubes (Specify) <br /> Background and description of any previous investigation [I Ph Organic <br /> Vapor <br /> ion Detector <br /> or incidence: [I Organic Vapor Analyzer <br /> [] 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: °F (high ambient temp.) <br /> [] Noise Source: <br /> [ <br /> 2. Personal Protective Equipment I Oxygen Deficiency: Level of Protection: [JA [JB [JC [JD <br /> [] Excavation: (falls, trips ,slipping, cave-ins) [I Hard hat <br /> [J Handling and Transfer of a Hazardous Substance: [] Safety giasses/goggies <br /> (fire, explosions, etc.) [I Steel toed/shank shoes or boots <br /> [I Confined Space entry: (explosions) [J Flame retardant coveralls <br /> [I Heavy equipment (physical injury & trauma resulting [] Hearing protection <br /> from moving equipment) [I Tyvek <br /> [J Other, specify [I Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> 7. Anticipated Biological Hazards: [I Safety vest <br /> [J Snakes [j Insects [I RodentsPoisonous Plants [I Two-way communication <br /> (] <br /> [] 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): Plait Prepared by: Date: <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br />