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PQu cry. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAJOAQUIN COUNTY 4(j�! - N <br /> ProgramCoortinators <br /> 0 ft <br /> Donna K.Heran,R.E.H.S. Kase L.Foley,R.E.H.S. <br /> , Director 1$68 E. Hazelton Ave., Stockton,California 95205 �' Y, <br /> Telephone:(209)468-3420 Fizz:(209)468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Web:www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: March Lane Shell 1. Chemicals Hazards <br /> Address: 1206 E March Lane ❑Carcinogens: <br /> Contact Person: Parmeet Dhaliwal ❑Corrosives: <br /> Phone#: (51 D) 857-7816 ❑Dusts: <br /> Proposed Date of investigationfinspection:Apr 16, 2013 Explosives:Gasoline <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 ❑Oxidizers: <br /> Tank/Pipe Removal ❑Re-excavation ❑PCBs: <br /> ❑Sampling ❑BoringlMonitoring well installation ❑Other: <br /> ®Hazardous Waste inspection ❑Tiered Permitting inspection <br /> ❑Hazardous Materials Business Plan 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(speci fy): <br /> 4. Type of Operation: Retail Gas Station ❑Photo ionization Detector <br /> ❑Organic Vapor Analyzer <br /> 5. Release History: ❑Other(specify): <br /> Evidence ofleaks/soil contamination: ❑YES ©NO ❑None(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health&Safety Physical Concerns:(check all that apply& Level of Protection: ❑A ❑B ❑C N D <br /> describe) Hard Hat <br /> ❑Heat or Cold Stress: IF(high ambient temp.) ® Safety Glasses/Goggles <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> ®Excavation(falls,trips,slipping,cave-ins): ® 1 fearing protection <br /> ❑Handling and Transfer of a Hazardous Substance(fire,explosions,etc.);. ❑Tyvek <br /> ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge: <br /> N Heavy equipment(physical injury&trauma resulting from moving N Safety vest <br /> equipment): N Two-way communication <br /> ❑Other(specify): ❑Other(specify): <br /> 7. Anticipated Biological Hazards: PART IV <br /> ❑Snakes N Insects ❑Rodents ❑Poisonous Plants PLAN APPROVAL <br /> ❑Other/Unknown(specify): <br /> Plan Prepared by: 'Garrett Backus Date: Apr 15,2413 <br /> S. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.): <br /> Plan Approved by: �� � Date; <br /> EH 23081 (8/21/2012) <br />