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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name:Tokay Shell L Chemicals Hazards <br /> Address:420 W Kettleman Ln Lodi,CA 95240 ®Carcinogens: oil.fuel <br /> Contact Person:Jas Bain No:(209)810-5679 ❑Corrosives: <br /> Sweeps Number. ❑Dusts: <br /> Proposed Date of investigation/inspection: 1-17-12 ❑ Explosives: <br /> ®Flammables:oil.fuel <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑TanWPipe Removal. ❑Re-excavation. ❑PCB's: cc��11 <br /> ❑ Installation of Borings/Monitoring Wells. ®Other:contaminated absorbent,drained uaed7l filters <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: 1. Monitoring Equipment(note:Monitoring instttunents must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:gas&smog station ❑ Detector Tubes(Specify). <br /> 5. Release History: ❑Photo ionization Detector. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Organic Vapor Analyzer. <br /> Documented Groundwater contamination: ❑YES ❑NO ❑Other,specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety <br /> Level of Protection: ❑A C ®D <br /> Physical Concerns:(check all that apply&describe) ❑B ❑ <br /> ®Hard Ha[. <br /> ® Heat or Cold Stress: 95°F(high ambient temp.) ®Safety Glasses/goggles. <br /> ®Noise Sources:traffic. <br /> ®Steel toed shank shoes or boots. <br /> ❑Oxygen Deficiency: <br /> ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ®Hearing protection. <br /> etc..): <br /> ❑Tyvek. <br /> ❑Confined space entry:(explosions): ❑Respirator. ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving AT 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): Plan Prepared by:Aris C(�accaaoit I� Date: I-18-12 <br /> ac <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Y u I Date: r <br /> e.g.,power lines,integrity of dikes,terain,etc.) <br /> EH 23081(12/17/2002) <br />