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ENVIRONMENTAL HEALTH DEPARTMENT Address: 414 W. Charter Way, Stockton, CA 95206 Contact Person: Jorge Ramirez Phone No: (209) 4634523 Sweeps Number: Proposed Date of investigation/inspection: September 10, 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. N Hazardous Waste Inspection ❑ Sampling. 3. Specific Site Information: Tank No.: Tank( Other: Tank Capacity: Tank Age: 4. Type of Operation: Automotives Repair 5. Release History: Evidence of leaks / soil contamination: ❑ YES ONO Documented Groundwater contamination: ❑ YES ONO Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Hear or Cold Stress: OF (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of Hazardous Substance: (fire; explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & traurtta resulting from moving equipment): ❑ Other, specify 7. 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.): UNKNOWN EH 23081 (12/17/2002) ❑ Carcinogens: ❑ Corrosives: _ N Dusts: N Explosives: N Flammables: N 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 [__113 N Hard Hat. N Safety Glasses/goggles. N Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. N Hearing protection. ❑ Tyvek. ❑ Respirator: A/P cartridge: ❑ APR ❑ SCBA N Safety vest. N Two-way communication. PART IV -PLAN APPROVAL c Plan Prepared b � Date: 0 Plan Approved by: Date: SAN JOAQUIN COUNTY Qy..: �� 'X Donna K Heron, RE.H.S. 304 East Weber Avenue, Third Floor Unit Supervisors Carl Borgman, R.E.H.S. • ' Director Al Olsen, R.E.H.S. Stockton, California 95202-2708 Mike Huggins, R.E.H.S., R.D.I. �q`/FORN`P Program Manager Telephone: (209) 468-3420 D ouglas W. Wilson, R.E.H.S. Margaret Lagorio, R.E.H.S. Laurie Co R.E.H.S. Fax: (209) 464-0138 Robert McClellon, R.E.H.S. ProgramManager Manager Mark Barcellos, R.E.H.S. SITE HEALTH AND SAFETY PLAN PART I PART11 GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name: Pit Stop Lube & Tune 1. Chemicals Hazards Address: 414 W. Charter Way, Stockton, CA 95206 Contact Person: Jorge Ramirez Phone No: (209) 4634523 Sweeps Number: Proposed Date of investigation/inspection: September 10, 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. N Hazardous Waste Inspection ❑ Sampling. 3. Specific Site Information: Tank No.: Tank( Other: Tank Capacity: Tank Age: 4. Type of Operation: Automotives Repair 5. Release History: Evidence of leaks / soil contamination: ❑ YES ONO Documented Groundwater contamination: ❑ YES ONO Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Hear or Cold Stress: OF (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of Hazardous Substance: (fire; explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & traurtta resulting from moving equipment): ❑ Other, specify 7. 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.): UNKNOWN EH 23081 (12/17/2002) ❑ Carcinogens: ❑ Corrosives: _ N Dusts: N Explosives: N Flammables: N 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 [__113 N Hard Hat. N Safety Glasses/goggles. N Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. N Hearing protection. ❑ Tyvek. ❑ Respirator: A/P cartridge: ❑ APR ❑ SCBA N Safety vest. N Two-way communication. PART IV -PLAN APPROVAL c Plan Prepared b � Date: 0 Plan Approved by: Date: