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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Cah, als Hazards <br /> Address:• ogees: <br /> Contact Pets n: r Phone No. 11C osives: <br /> Sweeps Number. 1 <br /> Proposed Date of investigation/inspection: losives: <br /> ables: <br /> 2. Description and brief narrative of inspection activity- [ ] 1 rganic Gases: <br /> New UST Installation [ ] UAR Investigation I etalstals: <br /> Closure in Place [] Tank/Pipe Repair Oxidizers: <br /> Tank/Pipe Removal [ ] Re-excavation PCBs: <br /> Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Infounation: REQUIRED PERSONAL PROTECTIVE <br /> Tank No._4- 1 Tank Capacity. EQUIPMENT <br /> Tank Contents'•- Tank Age: _J14arMJV\, <br /> Other. 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless rpropriate rationale or restrictions are <br /> C) Prov;Ae ) <br /> S. Release History- ELJldombustible Gas/ en Meter <br /> Evidence of leaks/soil contamination: E/YES [ ] NO I Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO I Photoionization Detector <br /> Background and description of any previous investigation I Organic Vapor Analyzer <br /> or ipcidence: 'D1Q6LJ maw&AzLt� ]Other, specify- <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Pot Health and Safety <br /> Phi oncerns: (check all that apply& describe) <br /> Cq e or Cold Stress: OF (high ambient temp.) <br /> 11 is <br /> isurce- <br /> S <br /> ,0-.10 . - - 2- Pers al Protective Equipment <br /> en Deficiency- u7v, of Protection: [ ]A [ ]B ]C <br /> avation: (falls, trips slipping, cave-ins) FAiid hat <br /> andling and Transfer of a Hazardous Substance: ety glasses/goggles <br /> (fire explosions, etc.) to shoes or boots <br /> �Ite,�toed/shank <br /> ed Space entry. (explosions) I F <br /> .1afte retardant coveralls <br /> U],C��eavy equipment (physical injury&trauma resulting 144qearing protection <br /> from moving equipment) I Tyvek <br /> ] Respirator, circle: APR or SCBA <br /> VOther, specify A/P cartridge: <br /> Safety vest <br /> 7. Anticipated Biological Hazards: Two-way communication <br /> [ ] Snakes [ ] Insects [] Rodents Poisonous Plants <br /> Other/Unknown (specify): 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.): Plan Prepared by. INV Date:Jw, <br /> Plan Approved by: 1 i - Date:'4� , dr- <br /> EH23081 (217/92) <br />