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law <br /> SITE HEALTH AND SAFETY PLAN <br /> PART PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Valley Pacific Petro-Im Services L Chemicals Hazards <br /> Address:930E Victor Rd Lodi CA 95240 N Carcinogens: oil fuel <br /> Contact Person:Mike Eliason No:209 993-7807 N Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigationtinspection:3-24-11 ❑Explosives: <br /> NFlammables: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 /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. ❑Other <br /> N HW inspection PART III <br /> 3. Specific Site Information: <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 /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:cardlock ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: [3 YES ❑NO ❑Organic Vapor Analyzer. <br /> Documented Groundwater contamination: <br /> [I YES C]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 /> 6. Potential Health and Safety 2. Personal Protective Equipment <br /> Physical Concerns:(check all that apply&describe) Level of Protection: ❑A ❑B ❑C N D <br /> N <br /> C1 Beat or Cold Stress: °F(high ambient temp.) Hard Hat. <br /> N Safety Glmses/goggles. <br /> N Noise Sources:traffic. <br /> N Steel toed/shank show or boots. <br /> C1 Oxygen Deficiency: <br /> C1Excavation:(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls. <br /> C1Handling and Transfer of a Hazardous Substance:(fire,explosions, N Hearing protection. <br /> etc..): ❑Tyvek. <br /> ❑Confined space entry:(explosions): ❑Respirator: ❑APR ❑SCBA <br /> N Heavy equipment(physical injury&trauma resulting from moving AT cartridge: <br /> equipment):big rigs N Safety vest. <br /> ❑Other,specify ❑Two-way communication. <br /> 7. Anticipated Biological Hazards: PART IV-PLAN APPROVAL <br /> ❑Snakes N Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared by:Aris Cacaoiit Date:March 24.2011 O <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: f u Date: 3 ( 1 1 <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />