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P <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: <br /> 1. Chemicals Hazards <br /> Address: &-3:2, E, G `r ( -Larcinogens: <br /> Contact Person: ,lel M ra l it, Phone No. 1ST- $ [J Corrosives: <br /> Sweeps Number: 2519' [ ] Dusts: <br /> Proposed Date of investigation/inspection: U k- [ ] Explosives: <br /> [L}-.51ammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ ] UAR Investigation [-j Metals: <br /> [ J Tank Closure in Place [ ] Tank/Pipe Repair [ ] Oxidizers: <br /> Wank/Pipe Removal [ ] Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Specific SiteI formation: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: 25M EQUIPMENT <br /> Tank Contents: Tank Age: U)L- <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: LA.6, (cm Fy-r -c^,_ �� unless appropriate rationale or restrictions are <br /> provided) <br /> S. Release History: WCombustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ I YES [+140 [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES i4_60 [ ] Photoionization Detector <br /> Background and description of any previous investigation [J Organic Vapor Analyzer <br /> or incidence: Aff [ J 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 /> 2. <br /> �oise Source: Personal Protective Equipment <br /> ( J Oxygen Deficiency: Level of Protection: [ ]A [ JB [ ]C 140- <br /> [-I-Ex-cavation: (falls, trips ,slipping, cave-ins) H Har hat <br /> [-Yffa-ndling and Transfer of a Hazardous Substance: [ afety glasses/goggles <br /> (fire, explosions, etc.) (feel toed/shank shoes or boots <br /> [ J Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> [+ge-avy equipment (physical injury& trauma resulting LJ-Kearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ J Other, specify r/,9- A/P cartridge: <br /> [ J Safety vest <br /> 7. Anticipated Biological Hazards: [ J 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 by: Date: <br /> LFII'Dr TIzfF7C /iy H22.En9-- <br /> Plan Approved by: Date: <br /> • 12 <br />