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ENVIRONMENTAL HEALTH DEPARTMENT <br />°P"" c SAN JOAQUIN COUNTY <br />Donna K. Heran, R.E.H.S. Unit Supervisors <br />" I ` Director 304 East Weber Avenue, Third Floor Carl Borgman, R.E.H.S. <br />Mike Huggins, R.E.H.S., R.D.I. <br />Al Olsen, R.E.H.S. Stockton, California 95202-2708 Douglas W. Wilson, R.E.H.S. <br />cy F o t: a�P Program Manager Man ax: ( <br />Telephone: (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 <br />SITE HEALTH AND SAFETY PLAN Mark Barcellos, R.E.H.S. <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: Rvder <br />Address: 3633 Duck Creek Dr., Stockton, CA <br />Contact Person: Mark S. Koivisto Phone No: (916) 372-7500 <br />Sweeps Number: <br />Proposed Date of investigation/inspection: March 28, 2005 <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 />Wells. <br />® Hazardous Waste Inspection <br />❑ Sampling. <br />3. <br />Specific Site Information: <br />Tank No.: Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: Gas Station & Vehicle Maintenance <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 Concerns: (check all that apply & describe) <br />❑ Hear 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. Anticipated Biological 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.): UNKNOWN <br />EH 23081 (12/17/2002) <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 />❑ Oxidizers: <br />❑ PCB's.- <br />PART <br />CB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. 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 / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ t lame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />® Two-way communication. <br />PART IV - PLAN APPROVAL <br />C <br />Plan Prepared by: �`�� Date: <br />Plan Approved by: Date: <br />