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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. <br />Site Name: <br />1. Chemicals Hazards <br />Address: <br />Contact Person: Phone No. <br />[ J Carcinogens: <br />[ ] Corrosives: <br />Sweeps Number. <br />[ ] Dusts: <br />Proposed Date of investigation/inspection: <br />[ ] Explosives: <br />2. <br />Description and brief narrative of inspection activity- <br />[ ] Flammables: <br />[ ] Inorganic Gases: <br />[ ] New UST Installation [ J UAR Investigation <br />[ ] Metals: <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ J Oxidizers. <br />[ ] Tank/Pipe Removal [ ] Re -excavation <br />[ ] PCB's: <br />[ ] Installation of Borings/Monitoring Wells <br />3. <br />Specific Site Information: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. Tank Capacity- <br />EQUIpMEN'T <br />Tank Contents: Tank Age: <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />4. <br />Type of Operation: <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />5. <br />Release History: <br />provided) <br />[ ] Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />[ ] Photoicnization Detector <br />Background and description of any previous investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: <br />[ ] Other, specify. <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />6. <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Heat or Cold Stress: of (high ambient temp.) <br />[ ] Noise Source: <br />2. Personal Protective Equipment <br />[ ] Oxygen Deficiency: <br />Level of Protection: [ ]'°' [ JB [ JC [ JD <br />[ ] Excavation: (falls, trips ,slipping, cave-ins) <br />[ J Hard hat <br />[ ] Handling and Transfer of a Hazardous Substance: <br />[ ]Safety glasses/goggles <br />(fire, explosions, etc.) <br />[ ] Steel toed/shank shoes or boots <br />[ ] Confined Space entry. (explosions) <br />[ ] Flame retardant coveralls <br />[ ] Heavy equipment (physical injury & trauma resulting <br />[ J Hearing protection <br />from moving equipment) <br />[ J Tyvek <br />[ ] Other, specify <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />[ J Safety vest <br />7. <br />Anticipated Biological Hazards: <br />[ J Two-way communication <br />( ] Snakes [ ] Insects ( ] Rodents [ ]Poisonous Plants <br />[ ] Other/Unknown (specify): <br />PART IV <br />FLAN APPROVAL <br />8. <br />Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by: Date: <br />Plan Approved by: Date: <br />EH23081 (2/7/92) <br />