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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />IVISION <br />SITE HEALTH AND SAFETY PLAN <br />'ART I <br />:NERAL SITE INFORMATION <br />Site Name: <br />Address: <br />ContactPerson: Phone No. <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />Description and brief narrative of inspection activity: <br />[ ] New UST Installation (] UAR Investigation 1 <br />(] Tank Closure in Place (] Tank/Pipe Repair <br />[ ] Tank/Pipe Removal [) Re -excavation <br />[ ] Installation of Borings/Monitoring Wells <br />Specific Site Information: <br />Tank No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Other: <br />Type of Operation: <br />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 />Potential *Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />(j Heat or Cold Stress: of (high ambient temp.) <br />() Noise Source: <br />[ ] Oxygen Deficiency: <br />[ j Excavation: (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 />( ] Other, specify <br />Anticipated Biological Hazards: <br />[ j Snakes;- [ ] Insects ( ] Rodents <br />[ J Other/Unknown (specify): <br />[ ] Poisonous Plants <br />Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />12 <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />[ ] <br />Carcinogens: <br />[ ] Corrosives: <br />(] Dusts: <br />[ ] <br />Explosives: <br />[ ] Flammables• <br />[ ] Inorganic Gases: <br />[ ] <br />Metals: <br />[ ] <br />Oxidizers: <br />[) PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />( ] 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 />Level of Protection: ( ]A [ ]B [ ]C [ ]D <br />[ J Hard hat <br />[ ] Safety glasses/goggles <br />[) Steel toed/shank shoes or boots <br />[ ] Flame retardant coveralls <br />[ ] Hearing protection <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />[ ] Safety vest <br />(] Two-way communication, <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: <br />Pian Approved by:' <br />Date: <br />Date: <br />