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SAN JOAQUIN COUNTY EINVIROiv�N-TAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chomicals Hazards <br /> Address: (-I'Carcinogens: <br /> Contact Person: -ePhone No. Corrosives: <br /> Sweeps Number- ///,f ( 'Dusts- <br /> Proposed Date of investigation/inspection: [ ] Explosives: <br /> []Flammables• <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> 144 New UST Installation [ ] UAR Investigation [ ] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: _ <br /> ["Tank/Pipe Removal [ ] Re-excavation [] PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. i/fl G%,-' 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: s 5A-- unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: E]"" ombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: (,;''S [ ] 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 /> 61 AGO 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: of (high ambient temp.) <br /> [ ] Noise Source: 2 Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Lev!1 of Protection: [ ]A [ ]B [ ]C [ ]D <br /> �x"Excavation: (falls, trips ,slipping, cave-ins) H J:Lud hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Fr Safety glasses/goggles <br /> (fire, explosions, etc.) []'Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> (tj 1 eavy equipment (physical injury& trauma resulting [:]' earing protection <br /> from moving equipment) [ ] Tyvek <br /> ( ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plant <br /> [ ] Other/Unknown (specify): PART N <br /> PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safery, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: "'zn Date: '- <br /> Plan Approved by. Date: <br /> EF.23081 (2/7/92) <br /> 1 <br />