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GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS 1. Site Name:City of Lodi White Slough Water Pollution Control Facility_ L Chemicals Hazards Address: 12751 N.Thomton Rd.Lodi CA 95242 ®Carcinogens:oil, Contact Person:Mike Schafer Phone#:209 3336868_ ❑Corrosives: Proposed Date of investigation/inspection:3-11-10 ❑Costs: ❑Explosives: 2. Description and brief narrative of inspection activity: ®Flammables:diesel fuel,oxygen ❑New UST installation ❑UAR Investigation ❑Inorganic Gases: ❑Tank Closure in Place ❑Tank/Pipe Repair ❑Metals: ❑Tank/Pipe Removal ❑ Re-excavation ❑Oxidizers: ❑Installation of Borings/Monitoring Wells ❑PCBs: Z Hazardous waste inspection ❑ Sampling ❑Tiered Permitting inspection PART III 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment(Note:Monitoring instruments must be used for all Tank No.: Tank Capacity: operations unless appropriate rationale or restrictions are provided): Tank Content: Tank Age: ❑Combustible Gas/Oxygen Meter Other: ❑ Detector Tubes(specify): ❑Photo ionization Detector 4. Type of Operation:Water Pollution Control Facility ❑Organic Vapor Analyzer ❑Other(specify): 5. Release History: ❑None(see below) Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: Documented Groundwater contamination: ❑YES ❑NO Background and description of any previous investigation or incidence: 2. Personal Protective Equipment Level of Protection: ❑A ❑B ❑C ®D 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) ®Hard Hat ❑Heat or Cold Stress: °F(high ambient temp.) ®Safety Glasses/Goggles ❑Noise Sources: ®Steel toed/sbank shoes or boots ❑Oxygen Deficiency: ❑Flame retardant coveralls ❑Excavation:(falls,trips,slippin&cave-ins): ®Hearing protection ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek etc.): ❑Respirator. ❑APR ❑SCBA ❑Confined space entry(explosions): A/P cartridge: ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest equipment): ❑Other(specify). ❑Two-way communication ❑Other(specify): 7. Anticipated Biological Hazards: ®Snakes ®Insects ❑Rodents ❑Poisonous Plants PART IV-PLAN APPROVAL ❑Other/Unknown(specify): l Plan Prepared by: � Date: q-1 -I -iy 8. Narrative(provide all information which could impact Health and Safety, `,.t. tv e.g.,power lines,integrity of dikes,terrain,etc.) Plan Approved by: Date: 'l EH 23081(3/10/2010)