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0 ** <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Jimco Truck Stop I. Chemicals Hazards <br /> Address: 1022 Frontage Rd.Ripon CA 95366 N Carcinogens: fuel <br /> Contact Person:Jamail Dhaliwal No:(209)599-2112 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigationtinspection: ❑Explosives: <br /> NFlammables: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 /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. N Other:contaminated absorbent <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 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:truck stop ❑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. Potential Health and Safety 2. Personal Protective Equipment <br /> Physical Concerns:(check all that apply&describe) Level of Protection: [I A [I B ❑C ND <br /> ®Hard Hat. <br /> N Heat or Cold Stress: °F(high ambient temp.) <br /> N Noise Sources:traffic ®Safety Glasshoes. <br /> ❑Oxygen Deficiency: ®Steel toed/shankrtardtshoes or boots. <br /> ❑Flame retardant coveralls. <br /> ❑Excavation;(falls,trips,slipping,cave-ins); <br /> ®Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <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): 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 Cacanit Date:4-16.13 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: ��11�- Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />