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R � i;0�\�F!nr�VTIiIL <br />SAiN IOAQUIN COTJ= ENNMONMEN T -AL. FMAL7H DIVISION <br />SITE HEALTH .HYD SAFE= PLAs� <br />?ART I <br />MENERAL SITE INFORMATION <br />i. Sire Name: <br />Address: / l <br />Coamc_ ?e_noa. Phoae No. <br />Sweeps Number: <br />Proposed Dare of iavestigadon/inspecson: <br />o D cipdoa and 'brief aa=dve of inspection ac=v* <br />New UST r + oa [ j UAP. Investigation <br />Tank C:osure is ?!ace t 1 Tank/Pipe Repair <br />. ank/Pipe Re=ova.L [ j qA__=varoa <br />(j U=rzaadon of Bor�=V/Monitoring Weds <br />3. Soecicc Sire ! r1'ot3ado= <br />Tank No. 1 a ;i' 3 -ank Caoaciry: o? <br />Tank COIIC_L : x.11 Tank <br />Other: <br />?. Tyne of Operadaa: ' <br />S. Release �.istorj: <br />­ride^ce of leaks/soil conrarninnnion: [ j _Ms [ j NO <br />Doc,== --red Groundwace-- contamination: C j -aS ( j NO <br />Back;sound and descbtion or any �rmou; =7es=gadoa <br />or incidence: � <br />'I- I A , <br />5. ?acendai miealdi and Saw <br />Ph cal Coerce.^ms: (check ail char nobly & descfle) <br />-eat or Cold Stress: ---y°:' (alga anbiesr mmp.) <br />Noise Source.• <br />( Oxygen Dedcie=cy: <br />�KExcavadoa: (falls, Sips ,suppiao cave-ins) <br />� angling and Transfer of a Hazardous Subsmnce: <br />(fire, explosions, etc.) <br />( j Conned Soace en=7- = iosions) <br />Heavy equipneat (pi ysicsl injury & Qauna resulting <br />iom Droving egmpmess) <br />Other, specify <br />7. Anricipared Biological F, -=ds: ro A <br />C I Snakes [ j Insects [ j Roden ( j Poisonous Piano <br />C I Ocher/Unlalown (specify): <br />8. Narmdve (provide ail info=adon which could inpac: Health <br />and Sarerq, e.; , Powe_- LL—.es , ince; sir of daces, : etc.): <br />E.-=081 (2/7/92) <br />?ART II <br />EVALUATION OF POTEN AL ARDS <br />1. ChenicaLs Hazards <br />,WT4.arcnoge^s-i f <br />[I Carroszves• <br />USES: <br />Ciat <br />[ I = tamma <br />C I Inorganic Cases- <br />[ IOmdize-s: <br />C I PC3's: <br />?ART t'II <br />REAL= PERSONAL PROTECME <br />EQUIP'Mo—J <br />1. Moniror=g `4 auiuxnenr: (note: Mon'irorin <br />:rust be used or ail ooeradons <br />unless aolomoram -arionaie ores c=ons are <br />Provided) <br />:ambos ble C-as/Oz7gen Mere_- <br />!! j Dete -or Tubes (Soeci y) <br />(j PL+ocoianizar on De <br />(j Organic Vapor Amaiyzer <br />[ T Ocher, spe=ir_ <br />If =onirormg :nst==Ppm are accused, <br />ratio We or acdvir/ /area res�.c_oas: <br />2 Pe=onai ?rorec^re Equipment <br />Lave! of P-ccec :an: CIA C IB C IC �(D <br />aar <br />Sazeq Siasses/;og.,es <br />Steel coed/shank shoes or boors <br />(j cane retardant coveralls <br />"r_eg proceczon <br />C I T7vek <br />(j Respirator, ccrde: ABR or SC3A <br />A/P ca.^dge: <br />,$?,Safery vest <br />[ j Two-way ca=unicadoa <br />PAP.T IV <br />PLAN APPROVAL <br />Amp prepare_ byv2t/� (. � Dare: <br />?!an Aporoved by. —`= Dare: <br />