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0 4 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name:USA Gas Station#68154 1. Chemicals Hazards <br /> Address:2500 W.Lodi Ave.Lodi,CA 95240 <br /> ®Carcinogens;fuel.diesel <br /> Contact Person:Sandy Edwards No:559 585-8156 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:June 22,2010 ❑Explosives: <br /> ❑Flammables:fuel,diesel <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR hrvestigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. ❑Other. <br /> ®HW inspection <br /> 3. Specific Site Information: <br /> PART IH <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:gas 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 /> Background and description of any previous investigation or incidence: If monitoring instruments are not used,rationale or activity/area restrictions: <br /> 6. Pm <br /> 2. Personal Protective Equipment <br /> Physical <br /> Health and Safety Level of Protection: El A ❑B C]C E D <br /> Physsical Concerns:(check all that apply&describe) ®Hard Ha[. <br /> C]Heat or Cold Stress: OF(high ambient temp.) <br /> ®Noise Sources:traffic. ®Safety Glasses/goggles. <br /> ❑Oxygen Deficiency: ®Steel toed/shank shoes or boots. <br /> ❑Excavation: Apingsli ,cave-ins):falls,trips, E]Flame retardant coveralls. <br /> ( p <br /> E]Handling and Transfer of a Hazardous Substance:(fire,explosions, ®Hearing protection. <br /> etc..): <br /> ElTyvek. <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): <br /> Plan Prepared by:Aris C`ac�ap_i't Date:June 21.20I0 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: kM`r Date: vyy q o <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />