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PART GENERAL SITE INFORMATION 1. Site Name: Grant Line Valero Address: 2420 W Grant Line Road, Tracy Contact Person: Victoria Silva Phone No: (209) 832-8273 Sweeps Number: Proposed Date of investigation/inspection: October 19, 2004 2. Description and brief narrative of inspection activity: ENVIRONMENTAL HEALTH DEPARTMENT °PQ�.1N SAN JOAQUIN COUNTY ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. Donna K. Heran, RE.H.S. Unit Supervisors ® Hazardous Waste Inspection Director 304 East Weber Avenue, Third Floor earl Borgtnan, R.E.H.S. • Al Olsen, R.E.H.S. Stockton, California 95202-2708 Mike Huggins, R.E.H.S., R.D.I. 1 cq.`�FOR��P Program Manager Telephone: (209) 468-3420 Douglas W. Wilson, R.E.H.S. Margaret Lagorio, R.E.H.S. If monitoring instruments are not used, rationale or activity / area restrictions: Laurie A.CoMR.E.H.S. Fax: (209) 464-0138 Progog ramam Manan ager Robert McClellon, R.E.H.S. Background and description of any previous investigation or incidence: SITE HEALTH AND SAFETY PLAN Mark Barcellos, R.E.H.S. PART GENERAL SITE INFORMATION 1. Site Name: Grant Line Valero Address: 2420 W Grant Line Road, Tracy Contact Person: Victoria Silva Phone No: (209) 832-8273 Sweeps Number: Proposed Date of investigation/inspection: October 19, 2004 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. ❑ Installation of Borings / Monitoring Wells. ® Hazardous Waste Inspection ❑ Sampling. PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards ❑ Carcinogens: ❑ Corrosives: ® Dusts: ® Explosives: ® Flammables: ® Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank No.: Tank Capacity: 1. Monitoring Equipment (note: Monitoring instruments must be used for all Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. Other: ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. 4. Type of Operation: Gas Station ❑ Organic Vapor Analyzer. El Other, specify. 5. Release History: Evidence of leaks /soil contamination: El YES ®NO If monitoring instruments are not used, rationale or activity / area restrictions: Documented Groundwater contamination: ❑ YES ® NO Background and description of any previous investigation or incidence: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ® D 6. Potential Health and Safety ® Hard Hat. Physical Concerns: (check all that apply & describe) ® Safety Glasses/goggles. ❑ Hear or Cold Stress: °F (high ambient temp.) ® Steel toed/shank shoes or boots. ® Noise Sources: Traffic El retardant coveralls. El Oxygen Deficiency: ® Hearing protection. ❑ Excavation: (falls, trips, slipping, cave-ins): El Tyvek. ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, ❑ Respirator: ❑ APR ❑ SCBA etc..): ❑ Confined space entry: (explosions): A/P cartridge: ❑ Heavy equipment (physical injury & trauma resulting from moving ® Safety vest. equipment): ® Two-way communication. ❑ Other, specify PART IV - PLAN APPROVAL 7. Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants Plan Prepared by: ate: - ❑ Other/Unknown (specify): Plan Approved by: Date: 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): UNKNOWN EH 23081 (12/17/2002)