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a.E >0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE HEALTH AND SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: Sam Motor Freight---- Address: reight_Address: 2929 S. Hwy 99, Stockto Contact Person: Philip Jennings Phone No: (770)232-4054_ Sweeps Number: Proposed Date of mvesugation/inspection: May 2010 2. Description and brief narrative of inspection activity: ❑ New UST installation.. ❑ UAR Investigation. ❑ Tank Closure in Place.. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ htstallation of Borings / Monitoring Wells. ® Hazardous waste inspection ❑ Sampling ❑ Tiered Permitting inspection 3. Specific Site Information: Tank No.: Tank Capacity: _ Tank Content Tank Age: Other: 4. Type of Operation: 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, et, i ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equipment): ❑ Other. specify Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (02/19/03) PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards ® Carcinogens: used oil ❑ Corrosives: ❑ Dusts: ❑ Explosives: ❑ Flammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D ® Hard Hat. ® Safety Glasses/goggles. ® Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator. ❑ APR A/P cartridge: ® Safety vest. ❑ Two-way communication. ❑ SCBA PART IV - PLAN APPROVAL Plan Prepared by: Ray von Plan Approved Date: 0415/10 Date: