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Aj <br />SAN JOAQUIN COUIPY ENVIRONMENTAL HEALT R VISION <br />SITE HEALTH AND SAFETY PLAN <br />ART I <br />ERAL SITE INFORMATION <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Site Name: SAO u1' <br />address: <br />Contact Person:. a ,. Phone <br />Sweeps Number: 1 7—Z& <br />Proposed Date of investigation/inspection: <br />Description and brief narrative of inspection activity: <br />ew UST Installation [ ] UAR Investigation Sa <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. Z Tank Capacity: ) <br />Tank Contents:Tank Age: t <br />other: <br />Type of Operation: Cyrls <br />Release History: <br />Evidence of leaks/soil contamination: YES [I NO <br />Documented Groundwater contamination: [ ] YES [TNO <br />Background and description of any previous investigation <br />or incidence: e±0 s '� <br />Potential *Health and Safety <br />Ph .cal Concerns: (check all that apply & describe) <br />[ Heat or Cold Stress: of (high ambient temp.) <br />[ ] Noise Source: <br />(]Oxygen Deficiency: <br />Mxcavation: (falls, trips ,slipping, cave-ins) <br />andling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] onfined Space entry: (explosions) <br />Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />[ ] Other, specify <br />Anticipated Biological Hazards: <br />[ ] Snakes;• [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />(] Other/Unknown (specify): <br />Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Lri <br />12 <br />Chemicals Hazards <br />[ Carcinogens: <br />[J Corrosives: <br />[ ] <br />Dusts: <br />xplosives: 6c, -& Iter <br />[ lammables:5-0/pv e <br />(] Inorganic Gases• <br />[ ] Metals: <br />[ ] <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 'd d) <br />(4 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 [ IC <br />[ ] Hard hat <br />[ J 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: <br />Plan Approved by:' Date• <br />