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SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />PART H <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name:a , G 1. <br />Address: % <br />Contact Person: Phone No, <br />Sweeps Number. <br />Proposed Date of investigarion/inspecrion: <br />2. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />�Tank/Pipe Removal [ ] Re -excavation <br />[ ]"Installation of Borings/Monitoring Wells <br />3. Specific Site Information: <br />Tank No. Tank Capacity: <br />Tank Contents: ,S9 It Tank A94- <br />Other. <br />4. Type of Operation: u r,L-, <br />S. Release History: <br />Evidence of leaks/soil contamination: /AYES [ ] NO <br />Documented Groundwater* contamination. [ ] [ ] NO <br />Background and description of any previous investigation <br />or inciden©c�e: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Heat or Cold Stress: of (high ambient temp.) <br />'Noise Source: _ ba_c_iT . <br />[ 1 Oxygen Deficiency: <br />Excavation: (falls, trips ,slipping, cave-ins) <br />Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ 1 Confined Space entry: (explosions) <br />Meavy equipment (physical injury & trauma resulting <br />from moving equipment) - - &,I, <br />[ 1 other, specify <br />7. Anticipated Biological Hazards: <br />[ ] Snakes [ 1 Insects [ 1 Rodents [ ] Poisonous Plants <br />[ J Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and Safery, e.g., power 1' es, integrity of dikes, terrain, etc.): <br />EH23081 (2/7/92) <br />Chemicals Hazards <br />cinogens• <br />[ ] Corrosives: <br />. <br />[.]'busts: <br />[ ] Explosives- <br />[ I Flammables• <br />lorgani <br />[Et-Metals: c G O L+!' 'ie2. ((3 <br />[ 1 Oxidizers: <br />[ 1 PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />Combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ ] Organic Vapor Analyzer <br />[ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: [ ]A [ ]B [ IC,�JD <br />�iard hat / ` <br />>Safety glasses/goggles <br />Steel toed/shank shoes or boots <br />[ ] Flame retardant coveralls <br />Hearing protection <br />[ 1 TYvek <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />Safety vest <br />'Two-way communication <br />PART IV ' <br />PLAN APPROVAL <br />Plan Prepared by: G G-' S Date: — 615 <br />Plan Approved by. 4QDate: <br />