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Name <br />In Gasoline <br />o Diesel <br />12 Waste Oil <br />Benzene <br />Ethylbenzene <br />District Use Only <br />Checked Against Reported Contaminants <br />SITE HAZARD INFORMATION <br />Please provide the following information for the site <br />Owner's Name: Chevron EMC <br />Site Address: 2103 Country Club Blvd., Stockton, CA <br />Consultant on Site: Bryan Sandor Phone No. (916) 889-6801 <br />Site Safety Officer: Bryan Sandor <br /> <br />Phone No. ( ) <br /> <br />Type of Facility: Former service station (currently a vacant fenced in lot) <br />Anticipated Hazardous Substances - (Attach Additional Sheets if Necessary) <br />(Please include concentrations below. Note if free product historically on site) <br />Expected Concentrations (ppm) <br />(List medium — i.e. soil, water, air) PEL (ppm) Health Effects <br />10,000 ug/L water NE irritation of eyes <br />140 ug/L water 1 ppm headache <br />180 ug/L water 100 ppm irritation of eyes <br />Site Safety Meeting Date: 1I3D Time: TED <br />Level of Personal Protection Equipment DA DB DC OD <br />Personal Protective Equipment: <br />R = Required A = As Needed, with description of action concentrations) <br />A <br />IZI 0 Hard Hat <br />121 0 Safety Shoes El <br />EZI 0 Orange Traffic Vest 0 <br />0 0 Hearing Protection 0 <br />0 0 Safety Eyewear 0 <br />A <br />CI Clothing (Type): long sleeves and long pants <br />0 Respirator (Type): <br />I: Cartridge (Type): <br />El Gloves (Type): <br />El Other: <br />Site Hazard Information Provided By: Ben Summersett Phone:(916) 865-0927 <br />Print <br />/.440•••'" <br />Date. 05/09/18 GHD/Scientist <br />Company name & title Signature