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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I <br />GENERAL SITE -INFORMATION <br />1. Site Name:. <br />Address: to <br />Contact Person: tl - Phone No. <br />Sweeps Number: <br />Proposed Date of investigation/inspection. <br />2. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />(j 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: 1310 <br />Tank Age: <br />Tank Contents: �(C CSS-�iCl�' g <br />Other: <br />4. Type of Operation: <br />Release History: <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />Documented Groundwater contamination: [ ] YES [ J NO <br />Background and description of any previous investigation <br />or incidence: <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Heat or Cold Stress: of (high ambient temp.) <br />FA Noise Source: <br />] Oxygen Deficiency: <br />[ xcavation: (falls, trips ,slipping, cave-ins) <br />] Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />[ j}hieavy equipment (physical injury & trauma resulting <br />/ from moving equipment) <br />[ ] Other, specify <br />7. Anticipated Biological Hazards: <br />[ j Snakes.- ( ) Insects [ ] Rodents <br />[ ] Other/Unknown (specify): <br />[ ] Poisonous Plants <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />12 <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />Carcinogens: <br />[) Corrosives: <br />[ ] Dusts: <br />Explosives: <br />Flammables: <br />] Inorganic Gases: <br />[ ] <br />Metals: <br />[ J Oxidizers: <br />[ ] 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 />[ J 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 [ ]C D <br />Hard hat <br />Safety glasses/goggles <br />Steel toed/shank shoes or boots <br />[ j Flame retardant coveralls <br />Hearing protection <br />Tyvek <br />Respirator, circle: AP or SCBA <br />A/P cartridge: <br />(J Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: - f . <br />Plan Approved by: <br />Date: /q <br />Date: GU I <br />