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.P <br />SAN JOAQUIN COUN 0 ENVIRONvIENTAL HEALTH AkISION <br />SITE HEALTH AND SAFETY PLAN <br />RTI <br />NIERAL SITE INFORMATION <br />PART II <br />EVALUATION OF POTENTIAL. HAZARDS <br />Site Name: 1. <br />Nddress: t&A=A' <br />Contact Person: - n6'u ,_v-Im _ Phone No. ?1,- %57 <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />De ription and brief narrative of inspection activity: <br />�tew UST Installation (J UAR Investigation 1 <br />( ] Tank CIosure in Place [ ] Tank/Pipe Repair <br />ank/Pipe Removal [ ] Re -excavation <br />[ ] installation of Borings/Monitoring Wells <br />Specific Site Information: <br />Tank No. 2, 3, Y2' _Tank Capacity:,t/ 8i°� <br />Tank Contents: Tank Age- rri <br />Other: <br />Type of Operation: Or?s SSS- 6le" <br />Release History: <br />Evidence of leaks/soil contamination: 14 YES [I NO <br />Documented Groundwater contamination: [ ] YES [TNO <br />Background and description of any previous investigation <br />or incidence: f'i�,ra tis" <br />:>�4 0001 <br />Potential'Health and Safety <br />Ph y ical Concerns: (check all that apply & describe) <br />(lj�Heat or Cold Stress: 'v _ of (high ambient temp.) <br />() Noise Source: <br />(] Oxygen Deficiency: <br />WF---cavation: (falls, trips ,slipping, cave-ins) <br />Iq Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />(Uonfined Space entry: (explosions) <br />eavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />[ ] Other, specify <br />Anticipated Biological Hazards: <br />[) Snakes; [ ] Insects [ ] Rodents <br />[ ] 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 />Chemicals Hazards <br />[dCarcinogens° i3av?e'P <br />[] Corrosives: <br />[ ] Dusts: <br />["xplosives: 6y,5 o/iA,oP <br />[0F'lammables: C�4ofi*�� - <br />[ ] Inorganic Gases: <br />[ ] Metals: <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 />pro ded) <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 Wi <br />(] 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: C Date: s%/ / <br />Plan Approved b'y-: Date: <br />