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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE HEALTH AND SAFETY PLAN PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: Country Market Cardlock I. Chemicals Hazards Address: 1524 Fresno Ave., Stockton ® Carcinogens: waste absorbent Contact Person: Mike Eliason Phone No: 933-8793 ❑ Corrosives: Sweeps Number: ❑ Dusts: Proposed Date of investigation/inspection: June 2010 ❑ Explosives: 2. 3. Description and brief narrative of inspection activity: ❑ New UST installation.. ❑ UAR Investigation. ❑ Tank Closure in Place.. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ Installation of Borings / Monitoring Wells. ® Hazardous waste inspection ❑ Sampling ❑ Tiered Permitting inspection Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: Retail Fuel 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. 7 Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ® Heavy equipment (physical injury & trauma resulting from moving eauioment): ❑ Other, specify Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Other/Unknown (specify): ❑ Poisonous Plants 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (02/19/03) ® Flammables: drained used fuel filters, used hoses and nozzles ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat. ® Safety Glasses/goggles. ® Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ® Safety vest. ❑ Two-way communication. PART IV - PLAN APPROVAL Plan Prepared by: Ray von Plan Approved by: Date: 06/14/ 10 Date: