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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 2 Y- L Unit Supervisors <br /> Q. ?, Donna FL Heran,R.E.H.S. <br /> w man,R.E.H.S. <br /> Director 304 East Weber Avenue, Third Floor g <br /> Carl Bor <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> _ Douglas W.Wilson,R.E.H.S. <br /> C4C/FORa\P Program Manager Man Telephax: (one: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Co R.E.H.S. F209)464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager 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:WALMART STORE#2025 1. Chemicals Hazards <br /> Address:3010 W.GRANT LINE ROAD,TRACY,CA 95304 <br /> ®Carcinogens: <br /> Contact Person:TODD YOUNG Phone No:836-5786 ❑Corrosives: <br /> Sweeps Number: <br /> ®Dusts: <br /> Proposed Date of investigation/inspection: <br /> ❑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. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> ®Hazardous Waste Inspection ❑Sampling. PART III <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 STORE:OIL CHANGE,TIRE ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: El YES [I NO If monitoring instruments are not used,rationale or activity/area restrictions: <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 /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ® <br /> ❑Hear or Cold Stress: °F(high ambient temp.) Steel toed/shank shoes or boots. <br /> ❑Flame retardant coveralls. <br /> ®Noise Sources: <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑ Excavation:(falls,trips,slipping,cave-ins): El Tyvek. <br /> El Respirator: El APR ❑SCBA <br /> ElHandling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): A/P cartridge: <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 — Date: <br /> ❑Snakes ElInsects ElRodents [IPoisonous Plants ,44 0 <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: 11 Date: d <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 (12/17/2002) <br />