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PART I GENERAL SITE INFORMATION 1. Site Name: QB Rebuilders, Inc Address: 2325 W. Charter Way, Stockton, CA 95206 Contact Person: Kosal Vong Phone No: (209) 4670-490 Sweeps Number: Proposed Date of investigation/inspection: February 27, 2004 Description and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ Installation of Borings / Monitoring Wells. ® Hazardous Waste Inspection ❑ Sampling. 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: automotive manufacture 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Hear or Cold Stress: °F (high ambient temp.) ® Noise Sources: EQUIPMENT ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving eouinment): ❑ Other, specify Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): UNKNOWN EH 23081 (12/17/2002) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards ® Carcinogens: _ ❑ Corrosives: ® Dusts: ❑ Explosives: _ ® Flammables: ❑ Inorganic Gases: ® Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat. ® Safety Glasses/goggles. ® Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ® Safety vest. ® Two-way communication. PART IV - PLAN APPROVAL Plan Prepared by� `Date: Z Q Plan Approved b Date: ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY G?, Donna K Heran, R.E.H.S. Unit Supervisors a:�� l 11 = Director 304 East Weber Avenue, Third Floor Carl Borgman, R.E.H.S. ? Al Olsen, R.E.H.S. Stockton, California 95202-2708 Mike Huggins, R.E.H.S., R.D.I. Program Manager Telephone: (209) 468-3420 Douglas W. Wilson, R.E.H.S. Margaret Lagorio, R.E.H.S. Laurie A. Cotulla, R.E.H.S. Program Manager Fax: (209) 464-0138 Robert McClellon, R.E.H.S. Mark Barcellos, R.E.H.S. SITE HEALTH AND SAFETY PLAN PART I GENERAL SITE INFORMATION 1. Site Name: QB Rebuilders, Inc Address: 2325 W. Charter Way, Stockton, CA 95206 Contact Person: Kosal Vong Phone No: (209) 4670-490 Sweeps Number: Proposed Date of investigation/inspection: February 27, 2004 Description and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ Installation of Borings / Monitoring Wells. ® Hazardous Waste Inspection ❑ Sampling. 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: automotive manufacture 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Hear or Cold Stress: °F (high ambient temp.) ® Noise Sources: EQUIPMENT ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving eouinment): ❑ Other, specify Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): UNKNOWN EH 23081 (12/17/2002) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards ® Carcinogens: _ ❑ Corrosives: ® Dusts: ❑ Explosives: _ ® Flammables: ❑ Inorganic Gases: ® Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat. ® Safety Glasses/goggles. ® Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ® Safety vest. ® Two-way communication. PART IV - PLAN APPROVAL Plan Prepared by� `Date: Z Q Plan Approved b Date: