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1./ 14/ <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Woodbridge AM PM 1. Chemicals Hazards <br /> Address: 18806 N Lo Net Sacramento Rd Woodbridge.CA 952 _58 ®Carcinogens: diesel.gasoline <br /> Contact Person:Sandeesh Bola No:(916)834-9436 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:4-23-12 ❑Explosives: <br /> ®Flammables:diesel gasoline <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ®Metals:fuel filters <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 /> Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must used for all <br /> Tank Content: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gastoxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:gasoline station/mini mart ❑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: 90°F(high ambient temp.) ®Safety Glasses/goggles. <br /> ®Noise Sources:traffic <br /> ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: <br /> ❑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..): <br /> [I Confined space entry:(explosions): El Respirator El APR El SCBA <br /> ❑Heavy equipment(physical injury&trauma resulting from moving <br /> 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 Cacapit Date:4-23-12 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: U'� Date: v <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />