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EwI ONMENTAL HEALTH ]DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna K.Heran,R.E.H.S. Unit Supervisors <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> 11_li Mike Huggins,R.E.H.S.,R.D.I. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Douglas W.Wilson,R.E.H.S. <br /> Laurie .Cotulla R.E.H.S. <br /> Pr ram Ma ager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Prc gram Map ager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> SITE HEALTH AND SAFETY PLAN Mark Barcellos,R.E.H.S. <br /> PART I PART II <br /> GENERAL SITE INFORMA ION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Kwik Serve 1. Chemicals Hazards <br /> Address:950 W. 11'"Street Tracy,CA 95376 <br /> ❑Carcinogens: <br /> Contact Person:Mahesh Patel Phone No:(209)832-1810 ❑Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection:October 4.20N ®Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrati a of inspe tion activity: ®Inorganic Gases: <br /> ❑New UST installation. ❑U R Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Ta k/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑R -excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> ®Hazardous Waste Inspeci'on ❑Sai npling. PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tai k Capacity: _ 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: k Age: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Ta <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑ Detector Tubes(Specify). <br /> 4. Type of Operation:Gas Statin ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: El Other,specify. <br /> Evidence of leaks/soil con urination: <br /> ❑YES ®NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater cntaminatio : [I YES ®NO <br /> Background and description f any prevt us investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6, Potential Health and Safety Level of Protection: ❑A ❑B ❑C ®D <br /> Physical Concerns:(check al that apply k describe) ®Hard Hat. <br /> ® <br /> El Hear or Cold Stress:_-°F igh ambient temp.) Safety Glasses/goggles. <br /> ®Steel toed/shank shoes or boots. <br /> ®Noise Sources:Traffic <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑ Excavation:(falls,trips,slipping,cav -ins): <br /> ❑ <br /> ❑ Handling and Transfer of Hazardou Substance:(fire,explosions, Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(ex losions): A/P cartridge: <br /> ❑Heavy equipment(physic 1 injury&I rauma resulting from moving ®Safety vest. <br /> equipment): ®Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazar s: <br /> El Snakes <br /> Snakes Insects Rodents Poisonous Plants Plan Prepared ate: ` L <br /> ElOther/Unknown(specify): <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all inform 'on which ould impact Health and Safety, <br /> e.g.,power lines,integrity of ikes,terraii i,etc.):UNKNOWN <br /> EH 23081 (12/17/2002) <br />