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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />EVALUATION OF POTENTIAL ILLAZARDS <br />GES -FRAC SITE INFOWN1ATION <br />Site Name: <br />Address: H10 IN 4 <br />Contact Person: Phone No.` 'I, <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />>.. Description and brief narrative of inspection activity: <br />[ ] New UST Installation [ ] UAR Investigation <br />[ ] Tank Closure in Place [ ] Tank/Pipe Repair <br />[ ] Tank/Pipe Removal [ ] Re -excavation <br />[ ] <br />Installation of Borings/Monitoring Wells <br />tsl� _ l"l� e� <br />Vp3.i rc Site Information: <br />Tank No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Other: <br />4. Type of Operation: r ex Ci I "e_ <br />5. Release History: <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />Background and description of any previous investigation <br />or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ J Heat or Cold Stress: °F (high ambient temp.) <br />[ ] Noise Source: <br />[ ] Oxygen Deficiency: <br />[ ] cavation: (falls, trips ,slipping, cave-ins) <br />[ Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />[ ] Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />[ J Other, specify <br />7. Anticipated Biological Hazards: <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />EH23081 (2/7/92) <br />Chemicals Hazards <br />[rcinogens: — <br />orrosives: — <br />[ ] Dusts: <br />[ ] Explosives: — <br />ammables: _ <br />[ ] Inorganic Gases: <br />L,Wetals: <br />[ ] Oxidizers: <br />[ ] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />[ J Combustible Gas; Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ ] Organic Vapor Analyzer <br />[ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Lev of Protection: [ ]A [ ]B [ ]C Md <br />and hat <br />[ afety glasses/goggles <br />[44teel toed/shank shoes or boots <br />[ ] Flame retardant coveralls <br />Baring protection <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />cartridge: <br />[ Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: 00 Date: <br />Plan Approved by: Da <br />