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i <br /> r 4 ') <br /> . i <br /> SAY JOAQUN COUNTY E V1RO NTAL HEALTH DIVISION <br /> S= HEALTH ALD SAFETY PLANE { <br /> PART I PART II <br /> GZNB aF- SITE 1NFORMAMON EVAIMAMON OF POTENTIAL HAZARDS <br /> 1. Site Name: l s-k 't'r1,,- f4Dvyk L�-L- 1. Chemicals F--azards <br /> Address: 112S Aj It _ ', � Carcinogens: <br /> Contact Person: �GClt,i t tiro.-mac Phone No. aSG -ZS :( [I Corrosives: <br /> Sweeps Number: D' ' <br /> Proposed Date of investiprion/insoection: { I Explosives: <br /> Fiammables- <br /> 2. Description and brief narrative of inspection acdviry. [ I Inorganic Gases: <br /> [ ] New UST Installation [ j dAR Investigation— [] Metals: <br /> [ ] Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> M Tank Pipe Removal { I Re-excavation []PCB's: <br /> [ I Irzralladoa of Borings/Moaitoring Wells <br /> PART III <br /> 3. Soecific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: '30c, _%o0 0 EQUIPMENT <br /> Tank Contents: Tank Age: `1-1&<_ <br /> Ocher. 1. Monitoring Ecuipmenc (none, Monitoring <br /> instruments must be used for all operations <br /> s. Type of Operation: unless approiDnare rationale orre=c_ors are <br /> provided) <br /> S. Release History ><Combusucle Gas/Oxygen Meier t <br /> Evidence of leaks/soil contaminatiotu C ] YES [ I NO C I Detector Tubes (Specify) E <br /> Documented Groundwater contain-ination: [ I `�� C I NO [ ] Phocoionizarion Detector <br /> Background and descipcion of any previous invesd rion [I Organic Vapor Analyze-- <br /> or <br /> nalyze:or incidence: Ll k n a C I Other, spedsir <br /> If monirormg insrr menrs are not used, <br /> radonaie or ac wiry/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Conce-rns. (check all that apply & des��e) <br /> K Hear or Cold Stress: C) -t•°F (high ambient temp.) <br /> { ] Noise Source, 2. Personal Protective Equipment <br /> { ] Oxygen Deficiency: Level of Procecdoa: C IA [ ]B [ IC AD <br /> Kxcavarion: (falls, trips .slipping, cave-ins) P-tiwd hat <br /> andling and Transfer of a Hu;ardous Substance: {L?:ra�fe'-Y gasses/gogggies <br /> (fire, explosions, a=e) VI'S-teel coed/shank shoes or boors <br /> C I Confined Space entry: (explosions) C I Flame remrdanr coveralls <br /> Heavy epuipmenz (physical in' & trauma resulting (� earing protection <br /> L-om moving equipment) Tyvek <br /> [ I Respirator, circle: APR or SOBA <br /> C I Other, speciry A/P cartridge- <br /> [ I Safery vest. <br /> 7. Aadcipared Biological Hazards: C I Two-way co==cadon <br /> f ] Snakes ( ] Insects C I Rodents { ] Poisonous Plants <br /> C ] Othe-r/Uri :mown (specify): PAR.'r N <br /> PLAN APPW. VAL <br /> 8. Narrative (provide all information which could impact:teal ,7 <br /> and Safety, e--, power lines, incegr�ry of dikes, re-min, etc.): Plan Prepared by: _I �� Date.* ?` <br /> Plan Aoproved by: Dat . <br /> E"73081 (2/7/42) <br />