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SAN JOAQUIN COUNTY EN"VMONNMNTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART IT <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: C. <br /> Address: 1. Chemicals Hazards <br /> � <br /> Contact Person: Phone No. <br /> Sweeps Number. M1� (I Carcinogens: <br /> Corrosives: <br /> �X T$ Ousts: <br /> Proposed Date of investi gat ionrnspection: // — [9� <br /> I <br /> Explosives: l <br /> 2. Description and brief narrative of inspection activity: [I F C <br /> [j_Inorganic rganiG es• <br /> [] New UST InstallationA, <br /> [j LIAR Investigation etais: <br /> [) Tank Closure in Place [j Tank/Pipe Repair [j Oxidizers: <br /> [] Tank/Pipe Removal [J Re-excavation [I PCB's: <br /> [] Installation of Borings/M nitoring Wells <br /> XmAz- t,)WH4 GE 'cRA)2m,, fS C7-�`p,�c� PART Ilt <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other. <br /> 1. Monitoring Equipmenr. (note: Monitoring <br /> instruments must be used for all operations <br /> �. Type or Operation: � VL unless appropriate rationale or restrictions are <br /> 5. Release History: provided) <br /> [I Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: <br /> (I YES [I NO [j Detector Tubes (Specify) <br /> Documented Groundwater contamination: [I YES [j NO [] Photoionization Detector <br /> Background and,description f any previous <br /> s investigation <br /> or incidence: [I Organic Vapor Analyzer <br /> _ V71`� [I Other, specify: <br /> uS If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all hat apply & describe) <br /> [I Heat or Cold Stress: °F (high ambient temp.) <br /> Noise Source: 2. Personal Protective Equipment <br /> [I Oxygen Det"ic' nb <br /> Level of Protection: [JA [IB [ICD <br /> Excavation: (fall �oa <br /> in cave-ins) ><Hard hat <br /> [I Handling an raazardous Substance: Safe glasses/ <br /> (fire, explosions, etc.) �Safety � ,ogoles <br /> [) Confined Space en >-Y-5- el toed/shank shoes or boots <br /> P try (expl sions> [j Flame retardant coveralls <br /> [ ] Heavy equipment (physical njury & trauma resulting ';;!?�earing protection <br /> from moving equipment) [j Tyvek <br /> Other, specify c [I Respirator, circle: APR or SCSA <br /> A/P cartridge: <br /> 7. Anticipated Biological Hazards: N'ON F Safety vest <br /> [J Snakes [I Insects [) Rode is [j Poisonous Plants [j Two-way communication <br /> [] Other/Unknown (specify): PART IV <br /> 8. Narrative (provide all information which could impact Health PLAN APPROVAL <br /> and Safety, e.g., power fines, in grity of dikes, terrain, etc): P Y ate.Plan Prepared b • 7/lt��aa • f G <br /> Sclaw �- <br /> Plan Approved b •Date./? <br /> PP y ' � � <br /> EH23081 (2/7/9 Q' <br />