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SAN JC AQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATI N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: S Af 1�l 0IQ k 1. Chemicals Hazards <br /> Address: ° Carcinogens: <br /> Contact Person: Tne <br /> hone No.-, rtQ—33�{ - �G Corrosives: <br /> Sweeps Number: [IDusts: <br /> Proposed Date of investigection: Explosives: <br /> Flammables: <br /> 2. Description and brief narspection activity: [�Inorganic Gases: <br /> [ <br /> New UST InstallationInvestigation jK]Metals: <br /> []Tank Closure in Placek/Pipe Repair Oxidizers: <br /> []Tank/Pipe Removalxcavation KI PCB's: <br /> Installation of Boringsg Wells <br /> ., N. 1 , SO(�\ PARTIII <br /> 3. pecific Site InformaYhonREQUIRED PERSONAL PROTECTIVE <br /> Tank No. apacity: 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: unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: []Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contaminat on: []YES []NO []Detector Tubes(Specify) <br /> Documented Groundwater conta ation: []YES []NO []Photoionization Detector <br /> Background and description of an previous investigation []Organic Vapor A alyzer <br /> or incidence: [Other,specify: t� e <br /> 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 /> VHeat or Cold Stress: °F(high ambient temp.) <br /> ,[a]Eloise Source: 2. Personal Protective Equipment <br /> ,.Oxygen Deficiency: Level of Protection: []A []B []C <br /> []Excavation:(falls,trips,slippin ,cave-ins) [Hard hat <br /> Handling and Transfer of a H ardous Substance: [ afety glasses/goggles <br /> (fire,explosions,etc.) [ Steel toed/shank shoes or boots <br /> []Confined Space entry:(explosi ns) []Flame retardant coveralls <br /> []Heavy equipment(physical inj &trauma resulting { Hearing protection <br /> from moving equipment) yvek <br /> espirator,circle: or SCBA <br /> []Other,specify A/P cartridge: <br /> Safety vest <br /> 7. Anticipated Biological Hazards: []Two-way communication <br /> []Snakes []Insects []Rodents []Poisonous Plants <br /> []Other/Unknown(specify): PART IV <br /> PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health l rl�� /���� <br /> and Safety,e.g.,power lines,inte .ty of dikes,terrain,etc.): Plan Prepared by:�'' 1l a ate: `7 <br /> Plan Approved by: Z� Date:4a <br /> EH23081 (2/7/92) <br />