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SAN JOAQUIN COUTT\Y MVVT_.FZONIMEN'IAL, F AL.TH DrVISION <br />SITE HEALTH .HYD S TY PLANT <br />?ART I PART II <br />GENU AI, SITE WORMATION EVALUATION OF P07MMAL F_V_ARDS <br />i. Site Mame: 1_ <br />Address: <br />ConmctPe_rson:/ &, Phone No. Zy 2-2 6 C -d e 0 <br />Sweeps Number: V <br />Proposed Date of investigation/inspecton: <br />2. Desc iptioa and brie: narrative of inspection a--'. <br />[ ] New UST InsmIl ation [ J LIAR Investigation <br />[ I Tank Closure in Place (] Tank/Pipe Repair <br />[ ank/Pipe Removal [ J Re -excavation <br />( ]installation of Bor�=gs/Monitoring Wells <br />3. Specific Site Information: <br />Tznk No. I Y7 / -0 1 Tank Capacity. J j <br />Tan:K Cptuemu: Tan:K A;e: <br />Other <br />Type or Ooe_ration: <br />3. Release History- '/ <br />sn <br />ridence of leans/soil conrariinadon: [ ]I VMS (f. <br />Docented Groundwater contamination: [ I ='v --S (4I <br />`+v <br />Backgound and des=- ton of any previous =vestigat on <br />or incidence: <br />5. Poceatial Healta and Safe_ry <br />P! ysi.cal Conce-^_s: (check all thar apply & desc:pe) <br />(at or Cold Stress: of (high aiemt temp.) <br />(�oise �Sout:e.• <br />(J O en Deficierc/: <br />[ =cavad'oa: (falls, trips ,supping cave-ins) <br />[ I <br />Handling and Transfe-r of a Hazardous Substance: <br />(Fre, erpiosiors, etc) <br />[ ] Confined Space enn-q.. (explosions) <br />[ I Heavy equipment (physical injury & mazu—na resulting <br />from moving equipment) <br />[ ] Other, specify <br />7. Anticipared Biological Hazards: <br />[ I Snakes [ I Insects [ I Rodents (J Poisonous Plants <br />[ I Other/Unlmown (speciy): <br />8. Narrative (provide all information which could bapact Health <br />and Safety, e.g., power I^es, .inter r/ of dices, :e_*im, etc.): <br />Z.H23081 (3/7/92) <br />chemicals Hazards <br />[ C ogens: <br />[ 1 Corrosives: <br />[1 <br />[�sives: <br />arn-0 les: <br />f 1 laor.-=*c Cases- <br />[ I Mem: <br />[ 1 Oaidize_*s: <br />[ J PCB's: <br />PART III <br />REQLMD PERSONAL PROTECTIVE <br />EQUIPM=IT <br />i. Monitoring Equipment: (note: Monitoring <br />-:meats must be used for all operadons <br />unless appropriate _adonaie or_estricrons are <br />pro ..eQj - <br />( Combus^Dle Gas/Oxygen Mete_- <br />(] Detector Tubes (Soecii-/) <br />[ I Photoionization Detecmr <br />[ J Organic Vapor Anaiyzer <br />[ 1 Other, spe=y. <br />If =onitorng h= :meats are not •:sed, <br />adonaie or activity /area reser:cons: <br />2 Personal Protec::ve Equipment ���/ <br />Lev of Protewon: ( ]A [ IB [ IC 19,1 <br />(_ard hat <br />(✓Safety gia sses/gog,es <br />(-s`teel toed/shank shoes or boots <br />�[ ]' /same retardant coveralls <br />Bit t searing protec.:ion <br />[ I Tyvek <br />(] Respirator, circie: APR or SC3A <br />A/P car• -cridge: <br />[ I Safety vest <br />[ I Two-way cotarzunicatron <br />PART r <br />PLAN APPROVAL <br />Plan Prepared br. Dare: --% 7 <br />?Ian• approved by. Date: <br />