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ENVIR0%IENTAL HEALT <br />EPARTMENT <br />Donna K. Heran, R.E.H.S. SAN JOAQUIN COUNTY <br />Program Coordinators <br />Director 600 E. Main Street Carl Borgman, R.E.H.S. <br />Laurie A. Cotulla, R.E.H.S. Stockton, California 9$202 Mike Huggins, R.E.H.S., R.D.I. <br />Assistant Director Kasey L. Foley, R.E.H.S. <br />Telephone: (209) 468-3420 Margaret Lagorio, R.E.H.S. <br />Fax: (209).464-0138 Robert McClellon, R.E.H.S. <br />Web: www.sjgov.org/ehd Jeff Carruesco, R.E.H.S. <br />SITE HEALTH & SAF&YaNAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Name:JIM THORPE OIL <br />Address:351 N BECKMAN RD <br />Contact Person: JAMEY THORPE Phone No:462-4581 <br />Sweeps Number: <br />Proposed Date of investigation/inspection:06/ 18/07 <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 />WellsIE iyy <br />® Hazardous waste inspection <br />❑ Sampling <br />❑ Tiered Permitting inspection <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: TRUCK SHOP/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 />6. Potential Health and Safety <br />Physical Conceipjr. Taheck all that apply & describe) <br />❑ Heat 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..): <br />❑ Confined space entry: (explosions): <br />® Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify: <br />7. Antic4*e#11061ogical Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />® Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxids2853Xi <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />I. 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 / ai6 rd3t ctions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />m ►� <br />❑ Respirator: ❑ APR ❑ SCKN <br />A/P cartridge: <br />® Safety vest. <br />❑ Two-way communication. <br />PART IV - PLAN APPROVAL <br />Plan Prepared byC'%�—��(%�y,/ <br />P1ai&pytpved by: v% <br />Datc: (1 17/40 <br />Date: <br />