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SAN JOAQUIN COUNTY aNVIRONM ENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTFNIIAL HAZARDS <br /> 1. Site Name: 6a4zeyo 1. call Hazards <br /> Address: Carcinogens: <br /> Contact Person:7Ter , UKpA Phone No. ,- 3-3 Z.4 7 []Corrosives: <br /> Sweeps Number. 2,>/7/C [ J Dusts: <br /> Proposed Date of investigation/inspection: A -11-9 ( Explosives: <br /> WFlammables: <br /> 2. Description and brief narrative of inspection activity: ( J Inorganic Gases: <br /> ( J New UST Installation [J UAR Investigation [] Metals: <br /> [ I Tank Closure in Place ( I Tank/Pipe Repair [ I Oxidizers: <br /> [t,j-fank/Pipe Removal [ I Re-excavation []PCB's: <br /> [ ] Installation of Borings/Monitoring Wells <br /> PART III <br /> 3. Soecific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No./ / D Tank Capacity: -. fA&L EQUIPMENT <br /> Tank Contents: lUeTank Age: <br /> Other: 1. Monitoring Equipment. (note: Monitoring <br /> instruments must be used for all operations <br /> 4. Type of Operation: unless appropriate rationale or restrictions are <br /> pro ' ed) <br /> S. Release History Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [ J YES [ ( I Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( NO [ hotoionization Detector <br /> Background and description of any previous investigation (I Organic Vapor Analyzer <br /> or incidence: ( ] 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 /> [ I Heat or Cold Stress: _ /j2DjL0F (high ambient temp.) <br /> [ ] Noise Source: 2. Personal Protective Equipment <br /> [ J Oxygen Deficiency: Lev/ek of Protection: [ IA [ ]B [ IC ( <br /> (excavation: (falls, trips ,slipping, cave-ins) [ d hat <br /> [�andling and Transfer of a Hazardous Substance: [ Safety glasses/goggles <br /> (fire, explosions, etc.) [WVSteel toed/shank shoes or boots <br /> ( J Confined Space entry: (explosions) ( ] Flame retardant coveralls <br /> [,J' eavy equipment (physical injury& trauma resulting (vj"Hearing protection <br /> from moving equipment) [ I Tyvek <br /> [ ] Respirator, circle: APR or SCBA <br /> [ J Other, specify A/P cartridge: <br /> [ I Safety vest <br /> 7. Anticipated Biological Hazards: ( I Two-way communication <br /> ( ] Snakes [ ] Insects ( J Rodents [ ] Poisonous Plants <br /> ( J 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, te-rrain, etc.): Plan Prepared by: Date: <br /> eaj e4 /T ,s <br /> Plan Approved by. Date: <br /> Ei 123081 (2/7/92) <br />