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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN - <br /> PART I PART H <br /> GENERAL SITE INFORMATION / EVALUATIOPI OF POTENTIAL HAZARDS <br /> 1. Site Name• �� ,5 SIZ 1. Ch 'c Hazards <br /> Address: [ ogees• <br /> Contact Person: lula4naw" Phone No. - 3� []Co slues: . <br /> Sweeps Number: xA22312 c/1 [ <br /> Proposed Date of investigation/inspection: G _"14-- losives: <br /> Flammables• <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation ( ] UAR Investigation [I Metals- <br /> L ] T/zik Closure in Place [] Tank/Pipe RePa L] oxidizers: <br /> N]/ ank/Pipe Removal [ ] Re-excavation. []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site In o tion: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. U ank Capacity: EQUIPMENT <br /> Tank Contents- Tank Age: <br /> Other. 1. Monitoring Equipment: (note: Monitoring <br /> instrum must be used for all operations <br /> 4. Type of Operation: unless ppropriate rationale or restrictions are <br /> �TV pro ed) <br /> S. Release History: -Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ I YES [ ] Detector Tubes (Specify) 1 <br /> Documented Groundwater contamination: L I YES CW/o/ <br /> O [ I Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: [ I Othe'. specify: <br /> If monitoring instruments are not used, <br /> i <br /> rationale or activity/area restrictions: <br /> b. Pozen •al Health and Safety <br /> Ph cal Concerns: (check all that apply& descri <br /> Heat or Cold Stress: of (high ambient temp.) <br /> [ ] No' Source: 2 Perso tective Equipment <br /> [ ] ypnD�ciency; Lev Protection: [ ]A [ ]B [ ]C ;;D <br /> vation: (falls, trips ,slipping, cave-ins) [ t <br /> ] andling and Transfer of a Hazardous Substance: S ty glasses/goggles , <br /> losions etc. <br /> L <br /> teel toed/shank shoes or boots <br /> (fiFav <br /> ) <br /> Bions ] Flame retardant coveralls <br /> [ ] CSpace entry. (explo ) L <br /> ] quipment (physical injury& trauma resulting [ ] Hearing protection <br /> from moving equipment) L ] Tyve <br /> [] Respirator, circle: APR or SCBA <br /> [ I 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 /> I� PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health /l J <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by. Date: I <br /> Plan Approved by: Date: <br /> EH23081 (2/7/92) <br /> L <br />