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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART 11 <br /> GENERAL SITE INFO TION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: , ?3nf—;. Carcinogens: <br /> Contact Person: Phone No. ]Corrosives: <br /> Sweeps Number. Dusts: e <br /> Proposed Date of investigation/inspection: 10 -93 [ ] Explosive . <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic G es: <br /> ew UST Installation [ ] UAR Investigation Metals: <br /> [ ] Tank Closure:n Place [ ] Tank/Pipe Repair [] Oxidizers• <br /> ank/Pipe Removal [J Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. P _'J—®2gTank Capacity: EQuEpmwr <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: r Vt unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History- Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: YES [ I NO [ ] etector Tubes (Specify) <br /> Documented Groundwater contamination. YES [ ] NO [ j Photoionization Detector <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: 17e, [ j Other, specify: <br /> r If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply&describe) <br /> Heat or Cold Stress: of (high ambient temp.) <br /> Oise Source: c 2. Personal Protective Equipment <br /> [ ] Oxygen Deficiency. Level of Protection: [ ]A [ ]B [ ]C D <br /> cavation : (falls, trips ,slipping, cave-ins) AHard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) [ j Steel toed/shank shoes or boots <br /> [ ] Confined Space entry. (explosions) [ j Flame retardant coveralls <br /> eavy equipment (physical injury& trauma resulting Baring protection <br /> from moving equipment) b azzk hax, Tyvek <br /> [ Jkespirator, circle: APR or SCBA <br /> Other, specify A/P cartridge: <br /> ® Mwo-way <br /> ety vest <br /> 7. Anticipated Biological Hazards: r[ 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. Date: <br /> Plan Approved by: Date: <br /> /&2 <br /> EH23081 (2/7/92) <br />