Laserfiche WebLink
SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> t. Site Name:Flag City Shell New West Station Inc I. Chemicals Hazards <br /> Address:6347 W Banner St.Lodi,CA 95242 <br /> ®Carcinogens:fuel, <br /> Contact Person:Bob Lackner No:916 443-0890 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:6-14-10 ❑Explosives: <br /> ❑Flammables: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 /> ®HW inspection <br /> 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:gas station ❑ Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: EI YES ED NO El Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> Documented Groundwater contamination: ❑YES ❑NO <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 ®D <br /> , <br /> ❑Heat or Cold Stress: °F(high ambient temp.) ®Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ®Noise Sources:traffic <br /> ®Steel toed/shank shoes or boots. <br /> C1 Oxygen Deficiency: <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Flame retardant coveralls. <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): ®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): Plan Prepared by:Aris Cac-apitDate:June 9,2010 <br /> VA8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: A Date: WI-to <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />