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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 Bor <br /> U � Uyti Laurie A.Cotulla,R.E.H.S. gman, R.E.H.S. <br /> Stockton, California 95202 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&YWAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:JIM THORPE OIL 1. Chemicals Hazards <br /> Address:351 N BECKMAN RD <br /> ❑Carcinogens: <br /> Contact Person:JAMEY THORPE Phone No:462-4581 ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection:06/18/07 ❑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 /> ❑Oxidi2853xi <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring WellsIE iyy <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:TRUCK SHOP/GAS STATION ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of leaks/soil contamination: YES F-1 NO <br /> If monitoring instruments are not used,rationale or activity/ai6 rd3t ctions: <br /> ❑ <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 Conceipjr.Taheck all that apply&describe) ®Safety Glasses/goggles. <br /> ® <br /> ❑Heat or Cold Stress: °F(high ambient temp.) Steel toed/shank shoes or boots. <br /> r_1 Flame retardant coveralls. <br /> El Noise Sources: <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑ <br /> ®Excavation:(falls,trips,slipping,cave-ins): Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator: El APR ❑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. Antic4*e6WWogica1 Hazards: IZ <br /> Plan Prepared by: <br /> El Snakes El Insects ❑Rodents C3 Poisonous Plants <br /> ❑Other/Unknown(specify): P1abFA ved b Date: <br /> PF)►) 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 />