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SAN JOAQUIN COUNTY ENVIROMMENTAL, HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br />.RT I P:kRT II <br />:,NERAL SITE <br /> 'INFOR.MATION EVALUATION OF POTENTIAL HAZARDS <br /> V <br /> Site Name: 1 I i aq e- �J� (� 1. Chemicals Hazards <br /> Address: [j Carcinogens: <br /> Contact Person: k Phone No.0 51 — GCl (] Corrosives: <br /> Sweeps Number: t0'7e Dusts: <br /> Proposed Date of investigation/inspection: Explosives: <br /> [] FIammables• <br /> Description and brief narrative of inspection activity: ( ] Inorganic Gases: <br /> ( ] Ne UST Installation ( ] UAR Investigation [ ] Metals: <br /> ( j nk Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> ( ank/Pipe Removal [ J Re-excavation [) PCB's: <br /> [ J Installation of Borings/Monitoring Wells <br /> PART III <br /> Specific Site Information: //�� REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: 67VW EQUIPI4IE-4T <br /> Tank Contents: Tank Age: k 01 <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> Type of Operation: unless appropriate rationale or restrictions are <br /> provided) . <br /> 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 /> 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 />( J Oxygen Deficiency: Level of Protection: [ ]A [ )B [ JC [ ]D <br />( J Excavation: (falls, trips ,slipping, cave-ins) ( ] Hard hat <br />( J Handling and Transfer of a Hazardous Substance: [ J Safety glasses/goggles <br /> (fire, explosions, etc.) ( ] Steel toed/shank shoes or boots <br />[ J Confined Space entry: (explosions) [ J FIame retardant coveralls <br />( J Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) ( J Tyvek <br /> ( j Respirator, circle: APR or SCBA <br />[ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> Anticipated Biological Hazards: [ ] Two-way communication <br />( ] Snakes; [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />( J <br /> Other/Unknown (specify): PART N <br /> PLAN APPROVAL <br /> 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:' Date: <br /> 12 <br />