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PART GENERAL SITE INFORMATION 1. Site Name: West Vallev Lube Center Address: 2615 W. Grunt Line Road. Tracy. CA Contact Person: Miguel Vargas Phone No: (209) 8364001 Sweeps Number: Proposed Date of investigation/inspection: February 24, 2005 2. Description and brief narrative of inspection activity: ❑ New UST installation. ENVIRONMENTAL HEALTH DEPARTMENT ❑ Tank Closure in Place. SAN JOAQUIN COUNTY ❑ Tank/Pipe Removal. Z. Z< K. , R.E.H.S. Donna KHeranREHS 304 East Weber Avenue, Third Floor Unit Supervisors Carl Borgman, R.E.H.S. • Director AI Olsen, R.E.H.S. Stockton, California 95202-2708 Mike Huggins, R.E.H.S., R.D.I. .:• CgC;FOfN`PProgram Manager Telephone: (209)468-3420 Douglas W. Wilson, R.E.H.S. Margaret Lagorio, R.E.H.S. Laurie A. Cotulla, R.E.H.S. Program Manager Fax: (209) 464-0138 Robert McClellan, R.E.H.S. Mark Barcellos, R.E.H.S. SITE HEALTH AND SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: West Vallev Lube Center Address: 2615 W. Grunt Line Road. Tracy. CA Contact Person: Miguel Vargas Phone No: (209) 8364001 Sweeps Number: Proposed Date of investigation/inspection: February 24, 2005 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. 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age: 4. Type of Operation: Gas Station & Lube Change 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) ❑ Hear 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, etc _). ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving eauinmentl. ❑ 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) PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards ❑ Carcinogens: ❑ 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 ® Hard Hat. ® Safety Glasses/goggles. ® Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ® Safety vest. ® Two-way communication 16T.1 14118 taUMNIF:1».TO"214 Plan Prepared b • Z_z � Date: Plan Approved by: &td_ — Date: KE