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SAN JOAQ IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Quick N Save I. Chemicals Hazards <br /> Address:1901 S.El Dorado St,Stockt n <br /> ®Carcinogens:Gasoline <br /> Contact Person:Mohamad Matar Phone No:948-3009 ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspec on:March 22,2007 ❑Explosives: <br /> ®Flammables:Gasoline <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑L AR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑ nk/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Be-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> ®Hazardous waste inspection ❑ Sampling PART III <br /> ❑Tiered Permitting inspection <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: I ank Capacity: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: I ank Age: operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑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: [I Other,specify. <br /> Evidence of leaks/soil contamination <br /> ®YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamina on: ®YES ❑NO <br /> Background and description of any pri Mous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C OD <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that app y&describe) ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: (high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> E]Excavation:(falls,trips,slipping, ave-ins): El Tyvek. <br /> ❑ <br /> El Handling and Transfer of a Hazar(ous Substance:(fire,explosions, Respirator: E]APR El SCBA <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions': ®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:3/22/07 <br /> ❑Snakes ❑Insects ❑Roder ts ❑Poisonous Plants <br /> ❑Other/Unknown(specify): <br /> Plan Approved by:_el Date: <br /> 8. Narrative(provide all information wh ch could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,te Tain,etc.) <br /> EH 23081 (02/19/03) <br />