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0 0 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Flame Mini Mart I. Chemicals Hazards <br /> Address: 1301 W.Kettleman Ln.Lodi,CA 95242 <br /> ®Carcinogens: Pas,diesel <br /> Contact Person:Ruuni Padda No:(209)334-3233 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspcetion:6-6-12 ❑Explosives: <br /> Wlammables:Ras.diesel <br /> 2. Description and brief initiative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. ®Other:contaminated absorbent <br /> ®HW inspection ❑Tiered Permit inspection <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:Ras station ❑Detector Tubes(Specify). <br /> 5. Release History: ❑Photo ionization Detector. <br /> Evidence of leaks/soil contamination: El YES ❑NO El Organic Vapor Analyzer. <br /> Documented Groundwater contamination: ❑YES ❑NO ❑Other,specify. <br /> Background and description of any previous investigation or incidence: If monitoring instruments are not used,rationale or activity/area restrictions: <br /> 6. Potential Health and Safety 2. Personal Protective Equipment <br /> Physical Concerns:(check all that apply&describe) Level of Protection: ❑A ❑B ❑C ®D <br /> ®Heat or Cold Stress: 95°F(high ambient temp.) ®Hard Hat. <br /> ®Noise Sources:traffic. ®Safety Glasses/goggles. <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): El Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Tyvek. <br /> ❑Confined space entry:(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P cartridge: <br /> equipment): ®Safety vest. <br /> ❑Other,specify ❑Two-way communication. <br /> 7. Anticipated Biological Hazards: PART IV-PLAN APPROVAL <br /> ❑Snakes ® Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): S� <br /> Plan Prepared by:Aris Cacaoit Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />