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• 4r. <br />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. Site Name: <br />I. Chpaiicals Hazards <br />Address: L u . <br />Carcinogens: <br />Contact Person: Phone No. /A. 6 3 T <br />[ j Corrosives: <br />Sweeps Number. 23l! 74 <br />CID ts: <br />Proposed Date of investigation/inspection: <br />losives: <br />[ lammables• <br />2. Description and brief narrative of inspection activity: <br />[ I Inorganic Gases: <br />[ I New UST Installation [ ] UAR Investigation <br />[ I Metals: <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ I Oxidizers: <br />[ ipe Removal [ j Re -excavation <br />[ ] PCB's: <br />[ ] Installation of Borings/Monitoring Wells <br />PART III <br />3. Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. / Tank Capacity: <br />EQUIPMENT <br />Tank Contents. /J- Tank Age: <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />4. Type Operation: S <br />instruments must be used for all operations <br />of n. <br />unless a ropriate rationale or restrictions are <br />' <br />Pd) <br />5. Release History: <br />Evidence of leaks/soil contamination: [ I YES C <br />[ Combustible Gas/Oxygen Meter <br />[ I Detector Tubes (Specify) <br />Documented Groundwater contamination: [ I YES [ NO <br />[ I Photoionization Detector <br />Background and description of any previous investigation <br />[ I Organic Vapor Analyzer <br />or incidence: <br />[ I Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />6. Potential Health and Safety <br />Pa1 Concerns: (check all that apply & describe) <br />J06at or Cold Stress: 40 'L ­OF OF (high ambient temp.) <br />[ Noise Source: <br />2. Personal Protective Equipment <br />[ J Oxygen Deficiency: <br />[cavation: (falls, trips <br />Levelof Protection: [ ]A [ ]B [ ]C [ <br />,slipping, cave-ins) <br />14_1qard hat <br />(41iandling and Transfer of a Hazardous Substance:[ <br />ery glasses/goggles <br />(fire, explosions, etc.) <br />[ teel toed/shank shoes or boots <br />[ I Confined Space entry. (explosions) <br />[ I Flame retardant coveralls <br />[ ] Heavy equipment (physical injury & trauma resulting <br />(wring protection <br />from moving equipment) <br />[ ] TWek <br />[ j Respirator, circle: APR or SCBA <br />(] Other, specify <br />A/P cartridge: <br />[ I Safety vest <br />7. Anticipated Biological Hazards: <br />[ ] Two-way communication <br />[ J Snakes [ I Insects [ ] Rodents [ ] Poisonous Plants <br />[ J Other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />8. 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: 7—�7 <br />EH23081 (2/7/92) <br />