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SctiNt JOAQUI`i COUNT`-�NVIR D MENTYPLAINHETH DI �3ION <br /> SITE HEALTH � <br /> PART II <br /> 1 EVALUATION OF POT&NTLA- HAZARDS <br /> R<1L SITE INFORMATION <br /> C:z <br /> A/�Gf� 1, emicals Hazards <br />:e name: [] Carcinogens: <br /> dress: 5 -:K-3y [l Corrosives: <br /> ntact Person: <br /> hone No( ( ] gusts: <br /> peeps Number. i ZoS�O Z �,C� ( ] Explosives: <br /> oposed Date of investigation/inspection: [] Flammables: <br /> [ ] Inorganic Gases: <br /> escription and brief nar alive of inspection activity [] Metals- <br /> UAR Investigation ( ] O.tidizers: <br /> Z <br /> US i Installation [ J Ta�PipeRepair Closure in Place [ I PC3's: <br /> /Pipe Removal ( J <br /> Re-excavation <br /> J Installation of Borings/Monitoring Wells PART III <br /> REQUIRED PHRSONAL PROTECTIVE <br /> oecific Site Information: �� _ EQUIP,%I&rT <br /> ank No. Tank Capaciry- ,, - <br />'ank Contents• Tank Age. "LTJ 1. Monitoring Equipment: (note: Monitoring <br /> I nk instruments must be used for all operations <br /> �v unless appropriate rationale or restrictions are <br /> iype of Operation: lS provided) n Meter[ ] Combustible Cas/Oxygen <br /> kelease History 1 ( ] Detector Tubes (Specify) <br /> ridence of leaks/soil contamination: [ ] S No ( ] Photoionization Detector <br />)ocumented Groundwater contamination: [ ] [] Organic Vapor Analyzer <br /> 3ackground and descriodon of any previous invesdgadon- [ ] Other, specify: <br /> 7r incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> Potential*Health and Safety <br /> Physical Concerns: (check all that aooly h bient temp.descri ) <br />( J Heat or Cold Stress: of �lg am2. Personal Protective Equipment <br />[ ] Noise Source: Level of Protection: [ ]A [ ]B [ ]C [ ]D <br /> ( ] Oxygen Deficiency: ( J Hard hat <br /> ( J <br /> Excavation: (falls, ceps ,slipping, cave-ins) _ [ ] Safety glasses/goggles <br /> ( ] Handling and Transfer of a Hazardous Substance: [ ] Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) ( j Flame retardant coveralls <br /> [ J Confined Space entry: (explosions) [ ] Hearing protection <br /> ] Heavy equipment ment (physical injury& trauma resulting [ ] Tyvek <br /> [ <br /> from moving equipment) [ ] Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> ( ] Other, specify [ ] Safety vest <br /> ( ] Two-way communication <br /> Anticipated Biologicaldaza ro <br /> Snakes; [ ] Insects d [ ] Poisonous Plants <br /> [ ] [ ] Rodents PART IV <br /> [ ] Other%Unknown (specify): -------------- PLAN APPROVAL. <br /> Narrative (provide all plan Prepared by: <br /> nformacion which could impact Health Date: <br /> and Safer/, e.g., power lines, integrity of dikes, terrain, etc.): <br /> o <br /> Plan Approved by: Date: <br /> t� <br />