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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PARTI PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name:COUNTRYSIDE MINI MART L Chemicals Hazards <br /> Address: 14971 N HWY 88 <br /> ®Carcinogens:USED ABSORBENTS <br /> Contact Person:KASHMIR SINGH Phone No:368.5380_ ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:APRILS,2008 E Explosives:USED FUEL FILTERS <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑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 /> E Hazardous waste inspection ❑ Sampling PART III <br /> ❑Tiered Permitting inspection <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. 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 El Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:RETAIL GASOLINE OUTLET ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of Teaks/soil contamination: ❑YES ❑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 ED <br /> 6. Potential Health and Safety E Hard Hat. <br /> Physical Concerns:(check all that apply&describe) E Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: OF(high ambient temp.) E Steel toed/shank shoes or boots. <br /> ❑Flame retardant coveralls. <br /> ❑Noise Sources: <br /> E Hearing protection. <br /> ❑Oxygen Deficiency: <br /> ❑❑Excavation:(falls,trips,slipping,cave-ins): ❑Respirator: ❑APR ❑SCBA <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): E Safety vest <br /> ❑Heavy equipment(physical injury&trauma resulting from 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:4/3/08 <br /> ❑Snakes ❑ Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terain,etc.) <br /> EH 23081(02/19/03) <br />