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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Econo Gas t. EhemieaIs Hazards <br /> Address:880 E Victor Rd <br /> ®Carcinogens:fuel <br /> Contact Person:Sukh Singh Phone No:(916)802-5776 ❑Corrosives: <br /> Sweeps Number: <br /> ®Dusts: <br /> Proposed Date of investigation/inspection:March 3.2009 ❑Explosives: <br /> ®Flammables:fuel <br /> 2. Description and brief narrative of inspection activity: <br /> ❑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. <br /> ®HW inspection <br /> 3. Specific Site Information: PART III <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 /> Other. operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:Retail Gas Station ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of teaks/soil contamination: El YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑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 /> Level of Protection: ❑A ❑B ❑C ZD <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ®Safety ed/Glashank hoes. <br /> ®Steel toed/shank shoes or boots. <br /> ®Noise Sources:traffic <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> ). ❑Respirator: [3 APR C]SCBA <br /> etc <br /> C1 Confined space entry:(explosions): cartridge: <br /> El Heavy equipment(physical injury&trauma resulting from moving ®SSafety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by:Aris Cacapit Date:March 3,2009 <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />