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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DIVISION <br /> SITE HEALTH AND SAFETY pl,,\N <br /> PART I PART 11 <br /> GENERAL SITE INFORMATION EVALUATION OF POTTNTIAL HAZARDS <br /> t <br /> 1. Site Name: r I c, 1. Chemicals Hazards <br /> Address: m5(4 // Carcinogens: <br /> Contact Person: Phone No. q.31 [I Corrosives: <br /> Sweeps Number usts: I <br /> Proposed Date of investigation/inspection: / Explosi s: e <br /> [] Flammables• <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> New UST Installation [ J UAR Investigation etals: <br /> L I Tank Closure in Place ( ] Tank/Pipe Repair [ ] Oxidizers: <br /> Tank/Pipe Removal [ ] Re-excavation []PCB's- <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTNE <br /> Tank No. , , 4- Tank Capacity: Iam16101'-9CW EQUIPMENT <br /> Tank Conre_drs: Tank Age: <br /> Other: F55X7 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> ?. Type of Operation: . Y unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release HistoryCombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ J YES ( ] NO [ J Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( I NO ( ] Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Healthand Safety <br /> Physical Concerns: (check all that apply& describe) <br /> [ ] Heat or Cold Stress: of (high ambient temp.) <br /> Noise Source: 2 Personal Protective Equipment <br /> ( j Oxygen Deficiency: Level of Protection: [ ]A [ ]B ( IC XD <br /> Excavation: (falls, trips ,siipping, cave-ins) Hard hat <br /> Handling and Transfer of a Hazardous Substance: Safery giasses/goggles <br /> (fire, explosions, etc.) : l-steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) ( j Flame retardant coveralls <br /> Heavy equipment (physical il'ury& trauma resulting. ><Hearing protection <br /> from moving equipmenr) z eila i— ba�m [ I Tyve-k <br /> ( ] Respirator, circle: APR or SCBA <br /> [ ] Other, specify A/P cartridge: <br /> afety vest <br /> 7. Anticipated Biological Hazards: VA Two-way communication <br /> [ j 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 bro. <br /> . Date: 1 <br /> Plan Approved by: Date: <br /> E.i-°:23081 (2/7/92) <br />