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' SAN JOAQUIN COt�N"tY EN VIRONNIENTAL HEALTH L[VISION w k <br /> e SITE HEALTH ANDVSAFETY PLAN % <br /> PART. PART II <br /> I <br /> GENERAL SITE INFORMATION „EVALUATION OF POTENTIAL HAZARDS <br /> + I. Chemicals.Hazards <br /> 1. Site Name: [Carcinogens: <br /> Address: „1 � Lei 'l 1)v- — w- -. <br /> Contact Person: 4 } 2� ko–n �7IA 9 41-I+-F�i� [] Corrosives:' <br /> Sweeps Number: s [ ] Dusts: <br /> Proposed Date of investigation/inspection: Ui�', [ ]'Explosives: - <br /> - EA Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> UAR Investi ation [] Metals: <br /> [ } New UST Installation [ ) $ , , <br /> [ ] Tank Closure in Place' [ ] Tank/Pipe Repair [ ] Oxidizers: Y <br /> [�Tank/Pipe Removal [ ] Re-excavation – – [] PCB's: <br /> I] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: f REQUIRED PERSONAL PROTECTIVE <br /> Tank No. ( f Tank Capacity: I( E4�ME ry <br /> Tank Contents: L. Tank Age: I TrS (P7-4) <br /> Other: 1�7J I. Monitoring Equipment: (note: Monitoring <br /> i` instruments must be used for all operations <br /> 4. Type of Operation: ]3,f` cc) unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release Histo " 41 Cvf Combustible Gas/Oxygen Meter <br /> �' JYES NO F ". [ ] Detector Tubes (Specify') , <br /> Evidence of.leakslsoil contamination: -[�1 [ J <br /> Documented Groundwater contamination: [ ] YES [v]'NO [ } Photoionization Detector #,- <br /> Background and description of any previous investigation [] Organic Vapor Analyzer: . <br /> or incidence: Other, specify: <br /> TE�ivK - t = 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 /> [dfNoise Source: 2. Personal Protective Equipment �,C <br /> Oxygen Deficiency: Level of Protection,:, [ `A . [ ]B [ ]C Liu <br /> [ xcavation: (falls, trips ,slipping, cave-ins) [✓rHard hat <br /> [lj 41andling and Transfer of a Hazardous Substance: [ afety glasses/goggles <br /> (fire, explosions, etc.) I (4-Ssteel toed/shank shoes-or boots <br /> [ ] Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [,]'Heavy equipment (physical injury & trauma resulting Hearing protection",t t <br /> from moving equipment) [ ] Tyvek'.- "` <br /> [ ] Respirator; circle: <br /> Y APR orp SCBA <br /> [ ] Other, specify. F A/P cartridge: T u V <br /> [ ] Safety vest" <br /> G1 [ ] Two-way communication` ,.t. <br /> 7. Anticipated Biological Haza <br /> [ } Snakes; [ } Insects [✓Rodents [ ] Poisonous plants <br /> [ ] Other/Unknown (specify): PART IV a <br /> ., PLAN APPROVAL - � <br /> 8. Narrative (provide all information which could impact Health 3 w <br /> and Safety, e.g., power Iines, integrity of dikes, terrain, etc.): Plan Prepared by: Date:. <br /> - _ Plan'Approved by: Date' <br /> T J. . <br />