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I <br /> ENVIRONMENTAL HEALTAEPARTMENT <br /> saPgtltry,Ca <br /> SAN JOAQUIN COUNTY <br /> Z' ':� Donna K.Heran,RE.H.S. Unit Supervisors <br /> H ' Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Al Olsen,RE.ILS. Stockton, California 95202-2708 Mike Huggins, R.D.I. <br /> • c.,. 'i• <br /> ProgramManaer Douglas W.Wilson, <br /> R.E.H.S. <br /> 4� PN` g Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> /FO <br /> Laurie A.Cotulla,RE.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellan,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:J D Service Station 1. Chemicals Hazards <br /> Address:9015 Walnut Grove,Thorton,CA ❑Carcinogens: <br /> Contact Person:Nasim Tarin Phone No:(209)794-8993 ❑Corrosives: <br /> Sweeps Number: E Dusts: <br /> Proposed Date of investigation/inspection:April 29,2005 E Explosives: <br /> E Flammables: <br /> 2. Description and brief narrative of inspection activity: E 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 /> E Hazardous Waste Inspection ❑Sampling. PART IH <br /> 3. Specific Site Information: I 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:Gas Station ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES E NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ENO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C E D <br /> 6. Potential Health and Safety E Hard Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> E Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) <br /> E Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> E Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> E]Respirator: [I APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving E Safety vest. <br /> equipment): E Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants plan Prepared by;- <br /> Date: �1 <br /> ❑Other/Unknown(specify): <br /> 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 />