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SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:USA Gas Station#68154 1. Chemicals Hazards <br /> Address:2500 W.Lodi Ave.Lodi,CA 95240 <br /> ®Carcinogens: fuel <br /> Contact Person:Stephen Coulter No:951-53M895 <br /> ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigationtinspection:3-28-13 ❑Explosives: <br /> EFlammables: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. <br /> El Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> ®HW inspection ❑Tiered Permit inspection E Other:contaminated absorbent <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 most 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: ❑YES ❑NO ❑Organic Vapor Analyzer. <br /> Documented Groundwater contamination: ❑YES <br /> ❑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) <br /> Level of Protection: ❑A ❑B ❑C E D <br /> E Heat or Cold Stress: 79 OF(high ambient temp.) E Hard Hat. <br /> E Noise Sources:traffic. E Safety Glasses/goggles. <br /> ❑Oxygen Deficiency: E Steel toed/shank shoes or boots. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ®Hearing protection. <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): 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): <br /> Plan Prepared by:Aris Cacaoi`t Date:3-27-13 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: J • Date: U '1 <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />