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SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name:United Gas 1. Chemicals Hazards <br /> Address:440 W.Charter Way,Stockt n <br /> ®Carcinogens:waste absorbent <br /> Contact Person:Tirath Gill Phone No:401-5831 ❑Corrosives: <br /> Sweeps Number <br /> ❑Dusts: <br /> Proposed Date of investigation/inspec ion:June 9,2009 ❑Explosives: <br /> ®Flammables:drained used fuel filters <br /> 2. Description and brief narrative of ins tion activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation.. ❑L AR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place.. ❑ Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑ -excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitorin Wells. <br /> ®Hazardous waste inspection ❑ ampling PART III <br /> ❑Tiered Permitting inspection <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: T Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: T 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 Gasoline Ou let ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ®YES NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> ❑ <br /> Documented Groundwater contaminatin: ®YES F1 NO <br /> Background and description of any preious 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 appli &describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> Oxygen Deficiency: ®Hearing protection. <br /> ❑ <br /> ❑Excavation:(falls,trips,slipping,caa-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardoi is Substance:(fire,explosions, C1 Respirator: C3 APR [_1 SCBA <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:Ray von Flue Date:June 9,2009 <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terra n,etc.) <br /> EH 23081(02/19/03) <br />