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• f 1 i <br /> i <br /> SA_N JOAQUIN COUi`1'1-`(" ENVIRONti(ENTAL HEALTH D...'15101i <br /> SITE FE.A.L i--I AND SAFETY PLAIN <br /> 1L SI�- <br /> INFORMATION EVALUATION OF POTZ:..AL HAZARDS <br />,e Name: <br /> l 1. C: �icals Hazards <br /> dress: (4Capcinogens: <br />'ncact Person: Phone No. �y� (] rrosives: <br /> / - <br /> ee?s Number: /'155zD u' <br /> oposed Dace of investigation/insDec,ion: L 7i ( Iosives: <br /> [ enables: <br />,sc.Mcion and brief narrative of inspector activity ( ] •norganic Gases: <br /> Ne, UST Installation [ ] UAR Investigation ( Metals: <br /> Tank Closure in Place [ ] Tar.:-/?ipe Repair ( ] Oxidizers: <br /> Lank/?:pe Removal ( ] Re•excavation <br /> Inscallacion of 3orings/Monicorng Wells <br /> ?.ART III <br /> ecific Sice Infoadon: REQUIRED PERSONAL PROTECr '_1VE <br />'rk No. rnTank Capacity OTD EQUIPl1dE:4T <br />.nk Contents: Tank Age: L H/l/ • <br />.'ger: 1. Monitoring Equipment: (note: Monitoring <br /> irsc-=encs crust be used for all operations <br /> 4e of Operation: (NVQ Ulr unless/appropriate rationale or res=cions are <br /> proylded) <br />!ease Hiscorry: [ Combustible Gas/Oxygen Meter <br /> idence of leaks/soil contaminacion: ( ( I NO ( ] Detector Tubes (Specify) <br /> cumented Groundwater contamination: [ :S [ ] NO [ ] Photoionizacion Detector <br /> cka,-pond and des -ioaon of any previous invesdgadon. (] Or;anic Vapor Analyzer <br /> incidence: [ j Other, specify <br />'7 If monicorng irstnumena are r.ot used, <br /> radonaIe or acci�ricy/area resccc^ons: <br /> cenc' 1 'Health and Safety <br /> Concerns: (check all that apply 3c descnbe) <br /> ac or Cold Stress: of (high ambient temp.) / <br /> Noise-Source: 2. Personal Protective Equipment <br /> O:tygen Dn <br /> eciency: Level, of?rocec:ion: ( IA ( )3 ( IC [� <br /> xcavac:on: (falls, crips ,slipping, cave-ins) Cd,/Fard hac <br />/Handling and Transfer of a Hazardous Substance: ( ksafecy glasses/goggles <br /> (fire, explosions, ecc.) ( Steel ed/shank. shoes or boon <br /> �cined Space envy: (explosions) ( j F e retardant coveralls <br />'Heavy equipment (physical injury & waur.a resulting ( .earing procec^'on <br /> from moving equipment) ( ] Tyvek <br /> ( ] Respirator, circle: APR or SC3A <br /> Other, specify Al? care:dge:— <br /> ( j Safety vest <br />,Icicipaced 3iological Hazards: ( J Two-way comriunication <br /> Snakes.- ( J Insects ( ] Rodents [ J Poisonous Plants <br /> Other/Unknown (speciry): PART N <br /> PLAN.APPROVAL <br /> anacive (provide all information which could impact Health Z� Cl <br /> d Safecy, e.;., power lines, integr ty of dikes, certain, etc.): Plan ?repared by: Dace: / <br /> Plan:Approved byr ^ Date: <br /> 12 <br />