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ENVIRONMENTAL HEALTH DEPARTMENT <br />Cq�/RO.rza\P <br />Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY program Coordinators <br />Director 1868 E. Hazelton Ave., Stockton, California 95205 Kasey L. Foley, R.E.H.S. <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S. <br />Web: www.sjgov.org/ehd Linda Turkatte, R.E.H. S. <br />SITE HEALTH & SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name: Premium Truck Service <br />Address: 1530 E Alpine Ave Stockton 95205 <br />Contact Person: Luis Hernandez <br />Phone #: 209-242-6721 <br />Proposed Date of investigation/inspection: 4/10/13 <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation <br />❑ UAR Investigation <br />❑ Tank Closure in Place <br />❑ Tank/Pipe Repair <br />❑ Tank/Pipe Removal <br />❑ Re -excavation <br />❑ Sampling <br />❑ Boring/Monitoring Well installation <br />❑ Hazardous Waste inspection <br />❑ Tiered Permitting inspection <br />® Hazardous Materials Business Plan <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: <br />Tank Age: <br />Other: Not applicable <br />4. Type of Operation: N/ <br />5. Release History: <br />Evidence of leaks/soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health & Safety Physical Concerns: (check all that apply & <br />describe) <br />❑ Heat or Cold Stress: IF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance (fire, explosions, etc.):. <br />❑ Confined space entry (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />® Other (specify): Unknown <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />® Other/Unknown (specify): <br />8. <br />Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): <br />EH 23081 (4/9/2013) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />❑ Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCBs: <br />® Other: Unknown <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (Note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided): <br />❑ Combustible Gas/Oxygen Meter <br />❑ Detector Tubes (specify): <br />❑ Photo ionization Detector <br />❑ Organic Vapor Analyzer <br />❑ Other (specify): <br />® None (see below) <br />If monitoring instruments are not used, rationale or activity/area restrictions: <br />This inspection does not require entry in to hazardous atmospheres <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <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: ❑ APR <br />A/P Cartridge: <br />❑ SCBA <br />❑ Safety vest <br />❑ Two-way communication <br />® Other (specify): Other safety equipment as dictated by business/conditions.- <br />PART IV <br />PLAN APPROVAL <br />9 <br />Plan Prepared by: Lowell Allen [EHl Date: <br />Plan Approved by: " °li_I/ Date: ` _(7 <br />