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ENVIRONMENTAL HEALTH DEPARTMENT <br />°P°L1N c <br />❑ New UST installation. <br />SAN JOAQUIN COUNTY <br />❑ Tank Closure in Place. <br />2. „—e•�.^-„ :2 <br />Q: a <br />a: <br />Donna K. Heran, R.E.H.S. <br />304 East Weber Avenue, Third Floor <br />Unit Supervisors <br />Carl Borgman, R.E.H.S. <br />rill! <br />Director <br />Al Olsen, R.E.H.S. <br />Stockton, California 95202-2708 <br />Mike Huggins, R.E.H.S., R.D.I. <br />Program Manager <br />-3420 (209) 468-3420 <br />Douglas W. Wilson, R.E.H.S. <br />Margaret Lagorio, R.E.H.S. <br />'FOR <br />Laurie A. Cotulla, R.E.H.S. <br />Program Manager <br />Fax: (209) 464-0138 <br />Robert McClellon, R.E.H.S. <br />SITE <br />HEALTH AND SAFETY PLAN <br />Mark Bareellos, R.E.H.S. <br />PARTI <br />PARTII <br />GENERAL SITE INFORMATION <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: TRACY GET N GO MART <br />Address: 574 W. GRANT LINE ROAD, TRACY <br />Contact Person: SATNAM SINGH / J. GILL Phone No: (209)833-3416 <br />Sweeps Number: <br />Proposed Date of investigation/inspection: MARCH 24, 2003 <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 />❑ Installation of Borings / Monitoring <br />Wells. <br />® Hazardous Waste Inspection <br />❑ Sampling. <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: GAS STATION <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 />UAR ON 01/23/1998 <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: °F (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, <br />etc -A <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />® Explosives: UST <br />® Flammables: FUEL <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <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 />If monitoring instruments are not used, rationale or activity / area restrictions: <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 ❑ SCI3A <br />A/P cartridge: <br />® Safety vest. <br />® Two-way communication. <br />PART IV - PLAN APPROVAL <br />r <br />Anticipated Biological Hazards: Plan Prepared by' ' Date <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): UNKNOWN Plan Approved by: Date: <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.): UNKNOWN <br />EH 23081 (12/17/2002) <br />