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SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Western Radiator Service of Lodi I. Chemicals Hazards <br /> Address: 12 S.Cluff Ave.Lodi CA 95240 ®Carcinogens: oil transmission fluid coolant <br /> Contact Pelson:Randy Stapleton No:(209)333-3763 ElCorrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of invesbgationlmspection: ❑Explosives: <br /> ®Flammables:oil <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:contaminated absorbent, — <br /> ®HW inspection ❑Tiered Permit inspection PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: <br /> 1. Monitoring Equipment(nota Monitoring instruments mus[be used for all <br /> Tank Content Tank Age:g : operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:radiator services ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other, specify. <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ®D <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat <br /> ®Heat or Cold Stress: 95°F(high ambient temp.) ®Safety Glasses/goggles. <br /> ®Noise Sources:traffic ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest <br /> equipment): <br /> ❑Two-way communication. <br /> E]Other,specify <br /> 7. Anticipated Biological Hazards: PART IV-PLAN APPROVAL <br /> ❑Snakes Z Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared by:Aris Cacamt Date: ( GGt� <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: I` Date: Ui 11� <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />