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SAN JOAQUIN COUNTY ENVIRON? I TAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAIN <br /> PART Il <br /> PART I <br /> GENERAL SITE INFORMATION SPrMC�- A5 0C-rT- �I EVAI-UA iTION OF POTENTIAL <br /> I. Checri`icals Hazards <br /> 1. Site Name: <br />` Address: (] Carcinogens• <br /> Phone No. [] Corrosives: <br /> Contact Person: — [ ] Dusts' I1 <br /> Sweeps Number: r <br /> Proposed Date of investigation/inspection: [] Flammables <br /> 2: Description and brief narrative of inspection activity: { ] Inorganic Gases: <br /> [ <br /> UAR investigation (] Metals:New LIST Installation [ 7 g i�. <br /> Tank/Pi a Repair <br /> [ ] O�ctdizers': <br /> [ ] Tank Closure in Place [ l P P s <br /> PCB's: <br /> Re-excavation [] <br /> � [ ] Tank/Pipe Removal [ ] II ' <br /> ( ] Installation of Borings/Monitoring Wells I <br /> PART 11! <br /> 3. Specific Site information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIP1VpIENT I' <br /> Tank Contents: L Tank Age: l I5k) I I <br /> Other: N I. Morlitoring Equipment: (note: Monitoring <br /> insnuments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> 4. Type of Operation:'. provided) .� <br /> S. Release History: [ ] Combustible Gas/Oxygen Meter <br /> YES [ ] NO [ ) Detectol Tubes (Specify) <br /> Evidence of leaks/sail contamination: ( ] YES photoionization Detector <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ ] Organic-Vapor Anal er <br /> Background and description of any previous investigation {J <br /> or incidence: [ ] Other, specify: <br /> io <br /> If mnitoring instruments are not used, <br /> rationale Jr activity/area restrictions: 3 <br /> 6. Potential'Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> [ ] Heat or Cold Stress: of (high ambient temp.) <br /> [ J Noise Source: 2. Personal Protective Equipment i <br /> Level of Protection: [ ]A [ ]B [ ]C [ ]D a <br /> [ ] Oxygen Deficiency: �s <br /> [ J Excavation: (falls, trips ,slipping, cave-ins) ( ]Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: ]'F Steetoed/shank glasses/goggles <br /> ass/gghles or boots <br /> (fire, explosions, etc.) <br /> [ ] Confined Space entry: (explosions) [ 3'�Flame':retardant coveralls <br /> (physical injury & trauma resulting [ ]r Hearing protection <br /> { ] Heavy equipment j ry r <br /> from moving equipment) ( ]!.Tyvek, <br /> [ ]i�rRespirstor, circle: APR or SCBA <br /> [ ] Other, specify I1'A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes;• [ ] Insects [ ] Rodents [ ] Poisonous Plants �! <br /> [ ] Other/Unknown (specify): PARTII,IV <br /> PLAN 1APPR OVAL , <br /> 8. Narrative (provide all information which could impact Health 1I I Date: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepar d by.. . <br /> Plan Approved by: Date: .^ <br /> 12 �. r� <br />