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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Arco Station I. Chemicals Hazards <br /> Address:800E Kettleman Ln,Lodi CA 95240 E Carcinogens: fuel <br /> Contact Person:Promod Trehan No:(209)334-3678 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:2-27-13 ❑Explosives: <br /> EFlammables:fuel <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation. ❑DAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. E Other:contaminated absorbent <br /> E 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 instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> [I Combustible Gas/Oxygen Meter. <br /> E]Detector Tubes(Specify). <br /> 4. Type of Operation:gas station <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: El YES ❑NO [-]Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 6. Potential Health and Safety 2. Personal Protective Equipment <br /> Physical Concerns:(check all that apply&describe) Level of Protection: [_1 A [-I B El C MD <br /> E Hard Hat. <br /> E Heat or Cold Stress: 67 IF(high ambient temp.) <br /> E Safety Glasses/goggles. <br /> E Noise Sources:traffic. <br /> E Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: <br /> ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> Hearing protection. <br /> E]Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> E <br /> etc..): [ITyvek. <br /> ❑Confined space entry:(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving A/P cartridge: <br /> equipment): E Safety vest. <br /> ❑Other,specify ❑Two-way communication. <br /> 7. Anticipated Biological Hazards: PART IV-PLAN APPROVAL <br /> ❑Snakes E Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared by:Aris Cacaoit 2 Date:2-27-13 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: U 1 Date: I L <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />