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vj <br />SAN JOAQUIN COUN i g ENVIRONMENTAL HEALTH VISION <br />SITE HEALTH AND SAFETY PLAIN <br />RT I <br />NERAL SITE INFORMATION <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Site Name•1. <br />address: SSD V%-Adi" <br />Contact Person: . 22a_a .7,;, - Phone No. 1711-- �ua5-•`i�c'l <br />Sweeps Number: 1266 <br />Proposed Date of invescigation/inspection: Ice i9qr <br />Dep •ription and brief narrative of inspection activity. <br />New UST Installation (:] UAR Investigation it <br />i ] Tank Closure in Place [ J Tank/Pipe Repair <br />ank/Pipe Removal (] Re -excavation <br />[ J installation of Borings/Monitoring Wells <br />Specific Site Information: <br />Tank No. ,2, 3, Y, 5" Tank Capacity: <br />Tank Contents: &<., Tank Age: err <br />Other: <br />Type of Operation: C's $�.trvN <br />Release History: <br />Evidence of leaks/soil contamination: (4YES (I NO <br />Documented Groundwater contamination: [ ] YES C TNO <br />Background and description of any previous investigation <br />or incidence: Witco -- <br />Potential *Health and Safety <br />Phy ical Concerns: (check all that apply & describe) <br />y� <br />[Heae or Cold Stress: 2 e) of (high ambient temp.) <br />[ ] Noise Source: <br />( ] xygen Deficiency: <br />Q,}�Excavation: (falls, trips ,slipping, cave-ins) <br />[Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ J onfined Space entry: (explosions) <br />Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />( ] Other, specify <br />Anticipated Biological Hazards: <br />[ ] <br />Snakes.- [ ] Insects ( ] Rodents <br />(] Other/Unknown (speci y): <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 />CiNI <br />12 <br />Chemicals Hazards <br />[ Carcinogens: /j'OLjZe-J <br />[ ] Corrosives: <br />[ ] Dusts: <br />(�cplosives: 6v,,- /�^,,e — <br />riammables• Gasolrve <br />[ ] Inorganic Gases: <br />[ ] Metals: <br />[ ] <br />Oxidizers: <br />[ J 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 />[ J 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 [ JC <br />[ ] Hard hat <br />[ ] Safety glasses/goggles <br />(] Steel toed/shank shoes or boots <br />[ ] Flame retardant coveralls <br />[ ] Hearing protection <br />[ J Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />[ ] Safety vest <br />[ J Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by: C Date: ALIVJI <br />4. <br />Plan Approved by: Date: <br />