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ENVI ONMENTAL HEALTH DEPARTMENT <br /> c SAN JOAQUIN COUNTY <br /> Unit Supervisors <br /> cr ?� Donn K.Heran,RE.H.S. P <br /> Direct r 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> A I Olsen, E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> �q <br /> Douglas W.Wilson,R.E.H.S. <br /> Lauri AA..Cotua,RE.H.S. p ( ) 42Margaret La.. �P Hager Telephone: 209 468-30 Mar orio,R.E.H.S. <br /> g <br /> ogram A17nager <br /> Fax: (209) 464-0138 Robert McClellon,R.E.H.S.SITE HEALTH AND SAFETY PLAN Mark Barcellos,R.E.H.S. <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:THE SERVICE ISTATIO 1. Chemicals Hazards <br /> Address:1100 W.11TH ST ET TRAY CA 95376 <br /> ❑Carcinogens: <br /> Contact Person:B.J. Phone No:(209)836-5203 ❑Corrosives: <br /> Sweeps Number: I Dusts: <br /> Proposed Date of investigate n/inspecti n:JUNE 04,2003 ❑Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrative of inspec tion activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ®Metals: <br /> ❑Tank Closure in Place. ❑Ta k/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/I donitoring Wells. <br /> ®Hazardous Waste Inspec on ❑Sa npling. PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tai ik Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tak Age: operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:MOTOR YCLE RI PAIR ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of leaks/soil cont.urination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any preVi DUS 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 apply k describe) ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ®Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑ <br /> E] Excavation:(falls,trips,s ipping,cav -ins): Tyvek. <br /> ❑ ❑ ❑ <br /> El <br /> and Transfer of Hazardou Substance:(fire,explosions, Respirator: APR SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(ex)losions): ®Safety vest. <br /> ❑Heavy equipment(physic il injury& raurna resulting from moving ®Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazar s: Plan Prepared by;41/&/��V_ <br /> Date: <br /> ❑Snakes ❑Insects Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify) <br /> Plan Approved by:� .� J Date: <br /> 8. Narrative(provide all info ,"on which ould impact Health and Safety, <br /> e.g.,power lines,integrityof ekes,terrai i,etc.):UNKNOWN <br /> EH 23081 (12/17/2002) <br />