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0 <br /> ENVIRONMENTAL HEALTH EPARTMENT <br /> ° SAN JOAQUIN COUNTY <br /> c: ?t Donna K. Unit Supervisors <br /> Heron,R.E.H.S. Carl Bor an,R.E.H.S. <br /> �': `�;' •. :< <br /> Director 304 East Weber Avenue, Third Floor Borg <br /> man, <br /> Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,Douglas W.Willson,sons.,R.D.I. <br /> � ,R.E.H.S. <br /> Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S, <br /> Mark Barcellos,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PARI'II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Joe's Travel Plaza 1. Chemicals Hazards <br /> Address: 15600 S.Harlan Road,Lathrop,CA <br /> ❑Carcinogens: <br /> Contact Person:Dawn Tafoya Phone No:(209)982-0341 ❑Corrosives: <br /> Sweeps Number: ® Dusts: <br /> Proposed Date of investigation/inspection:February 24,2005 ® Explosives: <br /> ® Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑ Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells.. <br /> Hazardous Waste Inspection ❑Sampling. 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 /> operations unless appropriate rationale or restrictions are provided) <br /> Tank Content: Tank Age:_ El Gas/Oxygen Meter. <br /> Other: <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:Gas Station ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of leaks/soil contamination: F-1 YES NO <br /> If monitoring instruments are not used,rationale or activity!area restrictions: <br /> � <br /> Documented Groundwater contamination: ❑YES ®NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ®D <br /> ❑ <br /> Physical Concerns:(check all that apply&describe) Hard Hat. <br /> ElHear or Cold Stress: °F(high ambient temp.) Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑ Flame retardant coveralls. <br /> Hearing protection. <br /> F_]Excavation:(falls,trips,slipping,cave-ins): <br /> F-1Handlingand Transfer of a Hazardous Substance:(fire,explosions, El Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest. <br /> equipment): ®Two-way communication. <br /> [:1 Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: t i <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> Plan Prepared by: ate: <br /> F_]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.):UNKNOWN <br /> EH 23081 (12117/2002) <br />