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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE DWORM&TION EV TION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: [I ' o . <br /> Contact Person: Phone No. []Corrosives: <br /> Sweeps Number. [I <br /> Proposed Date of investigation/inspection: [ ] Explosives: <br /> (I bles: <br /> 2. Description and brief narrative of inspection activity. [I Inorganic Gases: <br /> [ I New UST Installation [ ] UAR Investigation [I Metals: <br /> [ 1 <br /> Tank Closure in Place { I Tank/Pipe Repair [I <br /> [ I Tank/Pipe Removal [ I Re-excavation [] 's: <br /> [ ] <br /> Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific Site Information: REQUMED PERSONAL PROfMCTrVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other. I. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> provided <br /> S. ReleaseHistory: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [] YES [] NO [] Detector T (Specify) <br /> Documented Groundwater contamination: [] YES [ ] NO [I Photoionization Detector <br /> Background and description of any previous investigation [I Organic Vapor Analyzer <br /> or incidence: [I Other, specify: <br /> 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 /> [ I Noise Source: 2. Personal Protective Equipment <br /> [ IOxygen Deficiency: IATel of Protection: [ IA [ IB ;[ IC [ ID <br /> [ I Excavation: ( , trips AFPin& cave-ins) [.I Hard hat <br /> [I Handling and Transfer of a Hazardous Substance: [] Safety glasses/goggles <br /> (fire, explosions, etc.) [] Steel shoes or boots <br /> [ I Confined Space envy. (explosions) [I Flame retardant coveralls <br /> [ I Heavy equipment (physical *jury&trauma Ming [ I Hearing protection <br /> from movingequipment) [ I Tyvek <br /> [I Respirator, circle: APR or SCBA <br /> [I Other, specify A/P cartridge: <br /> [I Safety vest <br /> 7. Anticipated Biological Hazards: [] Two-way communication <br /> [ I Snakes [I Insects [] Rodents [ I Poisonous Plants <br /> [I Other/Unknown (specify): PART IV <br /> PLAN AL <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 /> 081 (2/7/92) <br />