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0 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Charter Way Chevron 1. Chemicals Hazards <br /> Address:508 W.Charter Way,Stockton <br /> ❑Carcinogens:used absorbents <br /> Contact Person:Surindcr Singh Saini Phone No:465-3440 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigationlinspection:October 18,2007 ❑Explosives: <br /> ❑Flammables:used fuel filters <br /> 2. Description and brief narrative of inspection activity: <br /> ❑ Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ®Hazardous waste inspection ❑ Sampling <br /> ❑Tiered Permitting inspection PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. 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:Retail Gasoline Outlet <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: El YES <br /> ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <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 Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Heat 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 /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ElHandling and Transfer of a Hazardous Substance:(fire,explosions, C]Respirator: [3 APR E]SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): Safety vest. <br /> Heavy equipment(Ph sical injury'&trauma resulting fom moving Two-way communication. <br /> equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: Plan Prepared by:Ray von Flue Date: 10/18/07 <br /> ❑Snakes ❑Insects ❑Rodents ❑ Poisonous Plants <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: date: <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 />