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SAN JOAQUIN CO S'qVIRONMEN7AL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />Site Name: <br />Address: <br />ContactPerson: Phone No. <br />Sweeps Number: <br />Proposed Date of investigationlinspection: <br />2. Description and brief narrative of inspection activity: <br />[ j New UST Installation (I UAR Investigation <br />[ j Tank Closure in Place ( J Tank/Pipe Repair <br />[ ] Tank/Pipe Removal [ I Re -excavation <br />(] Installation of Borings/Monitoring Wells <br />3. Specific Site Information: <br />Tank No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Other: <br />4. Type of Operation: <br />5. Release History: <br />Evidence of leakstsoil contamination: (] YES [ ] NO <br />Documented Groundwater contamination: ( j YES (I IVO <br />Background and description of any previous investigation <br />or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Heat or Cold Stress: °F (high ambient temp.) <br />[I Noise Source: <br />(j Oxygen Deficiency: <br />(I Excavation: (falls, trips ,slipping, cave-ins) <br />[ J Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />(j Confined Space entry: (explosions) <br />f 1 Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />[ ] Other, specify <br />7. Anticipated Biological Hazards: <br />[ I Snakes [ I Insects [ I Rodents [ j Poisonous Plants <br />[ 1 Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />1. Chemicals Hazards <br />(I Carcinogens: <br />[ J Corrosives: <br />H Dusts: <br />[ I Explosives: <br />f I Flammables• <br />f I Inorganic Gases: <br />(I Metals: <br />( I Oxidizers: <br />[ I 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 />( I Combustible Gas/Oxygen Meter <br />[ I Detector Tubes (Specify) <br />(J Photoionisation Detector <br />(J Organic Vapor Analyzer <br />f I 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 [ IB ( ]C [ JD <br />[ I Hard hat ; <br />( I Safety glasses/goggles <br />[ I Steel toed/shank shoes or boots <br />[ I Flame retardant coveralls <br />[ I Hearing protection <br />[I Tyvek <br />( I Respirator, circle: APR or <br />A/P cartridge: <br />[ I Safety vest <br />[ I Two-way communication <br />PART IV <br />PIAN APPROVAL <br />Plan Prepared by: Date: <br />Plan Approved by: Date: <br />EH23081 (2/7/92) <br />SC$A <br />