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i <br /> SAN JOAQUIN COU'NT'Y ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SPIE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Ch ' als Hazards <br /> Address• CZin [ c' ?gens: <br /> Contact Person: _ -f Phone No. 44 L0!4 7L4 2/ [XFlaa=mrnables: <br /> sives: <br /> Sweeps Number. DI [ : <br /> Proposed Date of investigation/inspection: '��� ( sives: <br /> 2. Description and brief narrative of inspection activity: { ] Inorganic Gases: <br /> [ ] NeST Installation [ ] UAR Investigation { ] Metals- <br /> [ ] 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: 22 REQUIRED PERSONAL PROTECTIVE <br /> Tank No. 6 ) _ _ Tank Capacity: `3 �D EQUIPMENT <br /> Tank Contents: Gg;:�2 Tank Age: 12 j�fs <br /> Other: T 1. Monitoring Equipment: (note: Monitoring <br /> instrumen must be used for all operations <br /> 4. Type of 0:eration: �cJC G. � c -�.� `��^ ��'�k unless propriate rationale or restrictions are <br /> pro ed) <br /> S. Release History: / [ ombustible Gas/Oxygen Meter <br /> Evidence of Teaks/sort contamination: { ] YES , Detector[ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ NO [ ] Photoionization Detector <br /> Background and description of any previous invest! io [] 6rganic Vapor Analyzer <br /> or incidence: NO �it�zc' e� o'/ �� ,aQ _,2,=�_ [ ] Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: i <br /> 6. Pot el Health and Safety <br /> Ph Concerns: (check all that apply& describe) <br /> e ' or Cold Stress: �0- OF (high ambient temp.) � <br /> [ o' Source: 2. Perso .Protective Equipment <br /> [ ] n Deficiency: Lev Pr ertian: [ ]A { 1$ [ ]C E I� <br /> [ vation: (falls, trips ,slipping, cave-ins) { t y <br /> { andliag and Transfer of a Hazardous Substance: [ S ety glasses/goggles <br /> (fire losions, etc.) { to oed/shank shoes or boots <br /> [ ] C ed Space entry: (explosions) { ] e retardant coveralls <br /> [ eavy equipment (physical injury&trauma resulting [Oiearing protection <br /> from moving equipment) { ];Tyvek ' <br /> [ ] Respirator, circle: APR or SCBA <br /> { ] Other, specify A/P cartridge: <br /> [ ],Safety vest <br /> 7. Antic' ated Biological Hazards: [ ] Two-way communication <br /> [ ] akes3 [ ] Insects [ ] Rodents [ ] Poisonous Plants <br /> [ Other/L1nkn?wn (specify): Yt n Si0,45— Baj 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: 2V Date: 6, f <br /> Plan Approved by.�g-�, _tJ Date•�. <br /> v <br /> EH23081 (2/7/92) <br /> „ <br />