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1* s <br />SAN JOAQUIN COUN TY -'-' "'MONNf EN7AL MA i.-1 XVISION <br />SIZ -1-MAL'M AND SAFFIFY PLAN <br />4 <br />PART I <br />GENERAL SITE INFORMATION PART U <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: <br />Address: <br />Contact Person:•Phone No. c <br />Sweeps Number.157 6� <br />Proposed Dare of investigation/inspection: <br />2. Description and brief narrative of inspection activity. <br />(] New UST Installation [J UAR Investigation <br />[ ] Tank Closure in Place [ J Tank/Pipe Repair <br />"'ank/Pipe Removal [ I Re -excavation <br />( ] Installation of Borings/Monitoring Wells <br />3. Specific Site Information: <br />Tank No. Tank Capacity: at <br />Tank Contents: r _ f` Tank Age: <br />Other. <br />4. Type of Operation: <br />S. Release History: <br />Evidence of leaks/soil contamination: [ I 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 />Heat or Cold Stress: °F (high ambient temp.) <br />Noise Source: <br />[ I Oxygen Deficiency: <br />Excavation: (falls, trips ,slipping, cave -fns) <br />[ I Handling and Transfer of a Hazardous Su7-- <br />(fire, explosions, etcj <br />[ ] Confined Space entry. (explosions) <br />Heavy equipment (physical injury & trauma resulting <br />from moving equipment) Be.C <br />[ I Other, specify <br />7. Anticipated Biological Hazards. <br />(] Snakes [ ] Insects [ I Rodents j ] PoisonousPlants <br />[ ] Other/Unknown (specify): PART IV <br />8. Narrative' (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc): <br />s t <br />,,, <br />EH23081 (?17/92) <br />1. Cnemicals Hazards <br />[ ] Carcinogens <br />[ I Corrosives: <br />Dusts: <br />[ I Explosives: <br />[ l Fiammabies: <br />[ I Inorganic Gases: <br />' Meds <br />[ I Oxidizers: <br />[ I PCB's: <br />PART III <br />REQUIRM PERSONAL <br />EQUIPMENT <br />1. Monitoring Equipment: (note: Monitoring <br />instruments mus be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />Combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ I Photoionisation Detector <br />[ ] Organic Vapor Analyzer <br />[ ] Other, speciry: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection:. [ ]A ( IB [ ICD <br />Hard hat r <br />Safety giasses/goggles <br />Steel toed/shank shoes or boots <br />[ I Flame remrdanr coveralls <br />Hearing protection <br />[I Tyvek <br />[ I Respirator, circle: APR or SCBA <br />A/P cartridge: <br />afe y vest <br />[ I Two-way communication <br />PLAN APPROVAL <br />Plan Prepared by, <br />r <br />Date: <br />Plan Approved br <br />Date: <br />