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SAN JOA UIN COUNTY EWIR0NMEN7AL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUAZION OF POTE.*ITIAL HAZARDS <br /> 1. Site Name: L 'l 1. Chemicals Hazards <br /> Address: [I Carcinogens: <br /> Contact Person: Phone No. oosives: <br /> Sweeps Number ` _ 5Drusrs- <br /> Proposed Date of investigatio inspection: Z=losives: <br /> [I Flammables• <br /> 2. Description and brief narrative of inspection activity. ( j Inorganic Gases: <br /> [ ] New UST Installation [ I UAR Investigation Metals: - -�P,/± <br /> [ ] Tank Closure in Place ( ] Tank/Pipe Repair [ ] Oxidizers: <br /> [ ] Tank/Pipe Removal [ j Re-excavation [] PCB's: <br /> I ]_1zI-i A2— or wgs Borings n � <br /> itoring Wells <br /> Ld �-�Az• r sPzC� �,� PART III <br /> Te Ge <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity EQUIPMENT <br /> Tank Contents: Tank:age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ins-umenrs must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History. [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil con ation: YES [ I NO [ I Derecror Tubes (Specify) <br /> Documented Groundwater coricaminarion. [ I YES ( ] NO [ j Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyze-, <br /> or incidence: U [ ] Other, specify <br /> If monitoring instr uments are not used, <br /> rationale or activiry/area restrcrions: <br /> 6. Potential Health and Safety t- <br /> Physical Concerns: (check all that apply & describe) <br /> [ ] Hear or Cold Stress: °F (high ambient temp.) <br /> Noise Source: 2. Personal Protective Equipment <br /> ( ] Oxygen Deacie. Level of Protection: [ ]A [ IB [ IC �] <br /> falls, trips sdpping, cave-ins) �E< Hard hat <br /> [ ] Handling an ransfe_r of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boors <br /> [ I Confined Space entry. ( losions) [ j Flame retardant coveralls <br /> [ I Heavy equipment (physic injury& trauma resulting ><Hearing protection <br /> from moving equipment) [ I Tyve-k <br /> [ ] Respirator, circle: APR or SCBA <br /> [ I Other, specify ia±i in t 5 I -� , A/P cartridge: <br /> Safety vest <br /> 7. Anticipated Biological Hazards: [ ] Two-way communication <br /> [ ] Snakes [ I Insects ( I Rodents [ I Poisonous Plants <br /> [ ] Other/Unknown (specify): G/}IUC�S _ 1 fin i f14/ PART IV <br /> ham!'f PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by. Dater <br /> Plan Approved by. Date: <br /> E:123081 (2/7/92) <br />