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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE I�Ii FORINIATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. site Narnje: ° 1. Chemicals Hazards <br /> Address: <br /> 1. Site Name: �t Carcinogens: <br /> '� <br /> Phone No. Corrosives: <br /> Contact Person: []Dusts: <br /> Sweeps Number: (] xplosives: <br /> Proposed Date of investigation/inspection: lammables: <br /> [] <br /> 2. Description and brief narrative of inspection activity: nic Gases: <br /> I etInorgaga <br /> (]New UST Installation []UAR Investigation []Oxidizers: <br /> []Tank Closure in Place []Tank/Pipe Repair [ ]PCB's: <br /> []Tank/Pipe Removal []Re-excavation <br /> []Installation of Borings/Monitoring Wells PART III <br /> 3. eci is Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment:(note: Monitoring <br /> instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> 4. Type of Operation: C provided) <br /> 5. Release History: []Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: []YES []NO []Detector Tubes(Specify) <br /> otoionization Detector ph <br /> Documented Groundwater contamination: []YES []NO []PhOrganic Vapor Analyzer <br /> Background and description of any previous investigation [] Oter,specify: <br /> n <br /> or incidence: (] p fy: <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 /> ambient to <br /> °F hi temp.)[]Heat or Cold Stress: (high 2. Personal Protective Equipment <br /> []Noise Source: Level of Protection: (]A []B []C <br /> []Oxygen Deficiency: — and hat <br /> [] cavation:(falls,trips,slipping,cave-ins) Safety glasses/goggles <br /> Handling and Transfer of a Hazardous Substance: Steel toed/shank shoes or boots <br /> (fire,explosions,etc.) ±(]Flame retardant coveralls <br /> []Confined Space entry:(explosions) Hearing protection <br /> eavy equipment(physical injury&trauma resulting []Tyvek <br /> from moving equipment) <br /> []Respirator,circle: APR or SCBA <br /> cartridge: <br /> []Other,specify Safety vest <br /> 7. Anticipated Biological Hazards: <br /> []Two-way communication <br /> []Snakes []Insects []Rodents []Poisonous Plants PART IV <br /> []Other/Unknown(specify): PLAN APPROVAL <br /> 8. Narrative(provide all information which could impact Health Plan Prepared by:Lk " Date: <br /> and Safety,e.g.,power lines,integrity of dikes,terrain,etc.):. <br /> Plan Approved by: Date• <br /> EH23081(2/7/92) <br />