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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Costco Wholesale#38 1. Chemicals Hazards <br /> Address: 1616 E Hammer Ln.,Stockton ❑Carcinogens: <br /> Contact Person:Dennis Back Phone No:(425)427-7653- ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:May 22,2007 ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ®Hazardous waste inspection ❑ Sampling PART III <br /> ❑Tiered Permitting inspection <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided) <br /> Other ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:Retail and Wholesale Sales ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> Other,specify. <br /> 5. Release History: ❑ <br /> If monitoring instruments we not used,rationale or activity/area restrictions: <br /> Evidence of leaks/soil contamination: [I YES ❑NO <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ®D <br /> ®Hard Hat. <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) ®Safety ed/Glashank shoes. <br /> ®Steel toed/shank shoes or boots. <br /> ❑ Heat or Cold Stress: 'F(high ambient temp.) <br /> ❑ ❑ <br /> Noise Sources: Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑Oxygen Deficiency: <br /> ❑Tyvek. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Respirator: C1 APR ❑SCBA <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> A/P cartridge: <br /> arc..): <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by:Ray von Flue Date:522/07 <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved b Date: <br /> PPro Y <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />