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,.,ddlk <br />SAN JOAQUIN COUN'TENVIRONMENTAL HEALTH AT"ISION <br />SITE HEALTH AND SAFETY PLAN <br />1T I <br />4MAL SITE INFOR36kTION <br />Site Name: <br />lddress: 160v2plA :L <br />,'ontact Persoim—, - Ic <br />'weeps Number. /AZ <br />Iroposed Date of investigacion/inspectiort: <br />Description and brief narrative of inspection activity. <br />I NeWUST Installation [ ] UAR Investigation <br />] ink Closure in Place C ] Tank/Pipe Repair <br />Tank/Pipe Removal [ ] Re -excavation <br />Installation of Borings/Monitoring Wells <br />Specific Site Information: <br />tank No. Tank Capacity: <br />tank Contents: ql�m <br />Zle' ' �"\' a "apTank Age: <br />)cher- <br />Type of Operation: Ala <br />Release History* <br />;vidence of leaks/soil contamination: C S HNO <br />)ocumenred Groundwater contamination: NO <br />lackground and des sript . on of any previous investigation - <br />)r incidence: <br />Potential . Health and Safety <br />Phys' <br />Potent" <br />(check all that apply & describe) <br />at or Cold Stress: OF (high ambient temp.) <br />No:s ounce: <br />L I O®n Deficiency: <br />aavation: (falls, trips ,slipping, cave-ins) <br />'ndling and Transfer of a Hazardous Substance: <br />(fire .,explosions, etc.) <br />U�rifined Space entry* (explosions) <br />eavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />( ] Other, specify <br />Anticipated Biological Hazards: <br />Snake&.- [ ] Insects C ] Rodents Poisonous Plants <br />Other/Unknown (specify): <br />,Narrative (provide all information which could impact Health <br />-nd Safety, e.g, power lines, integrity of dikes, terrain, etc.): <br />12 <br />PART Il <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Cl, micals Hazards <br />o ves: <br />losives: <br />F mables: <br />norganic Gases: <br />C Metals: <br />Oxidizers: <br />PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQuIPML-4T <br />1. Monitoring Equipment: (note: Monitoring <br />frostrum I is must be used for all operations <br />n,17�esppropriate rationale or restrictions are <br />tied) <br />ed) <br />Combusn"ble Cas/Oxygen Meter <br />Detector Tubes (Specify) <br />C Photoionization Detector <br />Organic Vapor Analyzer <br />Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area resa—ictfons: <br />2. <br />Personal Protective Equipment <br />Leve�,Of?rocecdon: []A [1B [1C <br />Fi,,,r-d' <br />at <br />C eEy glasses/goggles <br />C Stee�wed/shank <br />shoes or boots <br />C I F retardant coveralls <br />14 -gearing protection <br />Tyvek <br />Respirator, circle: APR or SCBA <br />A/P cartridge- <br />[ ] Safety vest <br />C ] Two-way communication. <br />PART IV <br />PLAN APPROVAL pV <br />Plan Prepared by: Data: <br />Plan Approved by: Date: <br />41D <br />