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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />SITE HEALTH AND SAFETY PLAN <br />PART I PART II <br />GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: 1. <br />Address• <br />Contact Person: Phone No. <br />Sweeps Number. ( % <br />Proposed Date of investigation/inspection: <br />2. 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 />[ Installation of Borings/Monitoring Wells <br />Chemicals Hazards <br />[ ] Carcinogens: <br />[] Corrosives: <br />j Dusts: <br />IK Explosives: <br />Flammables• <br />[ ] Inorganic Gases: <br />[ ] <br />Metals: <br />[ ] <br />Oxidizers: <br />[ ] PCB's: <br />PART III <br />3. Specific Site Information: 7 r -K REQUIRED PERSONAL PROTECTIVE <br />Tank No. _AS Tank Capacity EQUIPMENT <br />Tank Contents: Tank Age: <br />Ze- <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 />provided) <br />5. Release History: Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: (I YES [ kNO [ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: [ ] YES [ J NO [ ] Photoionization Detector <br />Background and description of any previous investigation [ ] Organic Vapor Analyzer <br />or incidence: [ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />b. 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: c 2. Personal Protective Equipment <br />(] Oxygen Deficiency: Level of Protection: [ JA [ ]B [4C 'M <br />ct,�- Excavation: (falls, trips ,slipping, cave-ins) K Hard hat - <br />[ J Handling and Transfer of a Hazardous Substance: r<T Safety glasses/goggles <br />(fire, explosions, etc.) ] Steel toed/shank shoes or boots <br />[ ] Confined Space entry. (explosions) [ ] Flame retardant coveralls <br />Heavy equipment (physical injury & trauma resulting ] Hearing protection <br />om moving equipment) Tyvek <br />[ Respirator, circle: or SCBA <br />[ I Other, specify A/P cartridge• <br />[ ] Safety vest <br />7. Anticipated Biological Hazards: [ ] Two-way communication <br />[ J Snakes [ ] Insects [ J Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): PART N <br />PLAN APPROVAL <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by-. _Date: ®` 19 <br />! <br />Plan Approved by: Date: <br />E:423081 (2/7/92) <br />