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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 EVALUATION OF POTENTIAL HAZARDS <br /> I- Site Name: J CE5 ML�r " 1'�r « 1. Chemicals Hazards <br /> Address: 3SS „ <br /> Contact Person: (Carcinogens: <br /> M�k�F4occ� _ Phone No. -4(oik_g333 [J Corrosives: <br /> Sweeps Number: [.Dusts: <br /> Proposed Date of investigation/inspection: q q <br /> I Expiasives: <br /> 2. Description and brief narrative of inspection activity: W-l-'Iammables: <br /> [I Inorganic Gases: <br /> [I New UST installation [] UAR Investigation (J Metals: <br /> [I Tank Closure in Place [J Tank/Pipe Repair [] Oxidizers: <br /> KTank/Pipe <br /> Removal [J Re-excavation [ J PCB's: <br /> Installation of Borings/Monitoring Wells <br /> 3. Specific Site Information: PART III <br /> REQUIRED PERSONAL PROTECTIVE <br /> No. i gQwO� Tank Capacity: 1 U pC.X'� EQUIPMENT <br /> Tank Contents: ice, ( Tank Age: <br /> Other: <br /> 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: `7evL, unless appropriate rationale or restrictions are <br /> 5. Release History: �prov ded) <br /> Evidence of leaks/soil contamination: Lombustible Gas/Oxygen Meter <br /> [J YES [:]'NO [J Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ I YES ;irNO [] Photcionization Detector <br /> Background and description of any previous investigation <br /> or incidence: [I Organic Vapor Analyzer <br /> (] 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 /> [rneat or Cold Stress: q, °F (high ambient temp.) <br /> K-Noise Source: Me-cy <br /> ,j.-]'Oxygen Deficiency 2- Personal Protective Equipment <br /> [] <br /> .[✓}'Excavation: (falls, trips ,slipping, cave-ins) ak( Level of Protection: []A 8 (IC v6 <br /> J-f-Fq­ard hat <br /> .J<Handling and Transfer of a Hazardous Substance: .{- Safety giasses/goggles <br /> (fire, explosions, etc.) Fy Mm"�C-s �,. reel toedishank shoes or boots <br /> [I Confined Space entry: (explosions) [J Flame retardant coveralls <br /> i,r-ieavy equipment (physical injury & trauma resulting ring protection <br /> from moving equipment) (J Tyvek <br /> [] Other, specify [I Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> [ <br /> 7. Anticipated Biological Hazards: wty vest I Snakes (J Insects [I Rodents C I Two-way communication <br /> (I Poisonous plants <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.): Pian Prepared by: 4Z4 _ Date: ' <br /> Plan Approved by: Date:ALI <br /> EH23081 (217/92) <br />