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SITE HEALTH AND SAFETY PLAN PART I PART II GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name:Countryside.Mini Mart 1. Chemicals Hazards Address: 14971 N Hwy 88 Lodi,CA 95240 N Carcinogens: diesel.gasoline Contact Person:Eddie Sandhu No:(209)368-5380 ❑Corrosives: Sweeps Number: ❑Dusts; Proposed Date of investigation/inspection:4-24-12 ❑Explosives: NFlammables:diesel.gasoline 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: ❑New UST installation. ❑UAR Investigation. N Metals:fuel filters ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: ❑Installation of Borings/Monitoring Wells. N HW inspection ❑Tiered Permit inspection N Other:contaminated absorbent 3. Specific Site Information: PART III Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all Other: operations unless appropriate rationale or restrictions are provided) ❑Combustible Gas/Oxygen Meter. 4. Type of Operation:gasoline station/mini mart ❑Detector Tubes(Specify). 5. Release History: ❑Photo ionization Detector. Evidence of leaks/soil contamination: ❑YES ❑NO ❑Organic Vapor Analyzer. Documented Groundwater contamination: ❑YES ❑NO ❑Other,specify. Background and description of any previous investigation or incidence: If monitoring instruments are not used,rationale or activity/area restrictions: 6. Potential Health and Safety 2. Personal Protective Equipment Physical Concerns:(check all that apply&describe) Level of Protection: ❑A ❑B ❑C OD N Heat or Cold Stress: 90 OF(high ambient temp.) N Hard Hat. N Noise Sources:traffic. N Safety Glasses/goggles. ❑Oxygen Deficiency: N Steel toed/shank shoes or boots. ❑Excavation:(falls,lips,slipping,cave-ins): El Flame retardant coveralls. ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, N Hearing protection. etc..): ❑Tyvek. ❑Confined space entry:(explosions): ❑Respirator: ❑APR ❑SCBA ❑Heavy equipment(physical injury&trauma resulting from moving. A/P cartridge: equipment): N Safety vest. ❑Other,specify ❑Two-way communication. 7. Anticipated Biological Hazards: PART IV-PLAN APPROVAL ❑Snakes N Insects ❑Rodents ❑Poisonous Plants ❑Other/Unknown(specify): Plan Prepared by:Aris Cacnaoit (� Date:4-24-12 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: U ` Date: is (-L- e.g.,power lines,integrity of dikes,terrain,etc.) EH 23081(12/17/2002)