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DRAFT <br /> SITE HEALTH AND SAFETY PLAN <br /> I. GENERAL SITE INFORMATION <br /> Site Name Tosco (Former Circle K) Store #1205 <br /> Site Address 16470 Cambridge Street at Louise Avenue, Lathrop <br /> Contact Person Mark Ca s Phone (916) 928-3300_ - <br /> Site I D Number 911-005 1C Proposed Date(s) of Site Work Pending <br /> II. DESCRIPTION OF INSPECTION ACTIVITY <br /> PRMose of Activity Type of Site <br /> ® Monitoring/extraction well installation ® Retail gas station/former gas station <br /> ❑ Vapor extraction well installation ❑ Petroleum Plant <br /> ❑ Well abandonment ❑ Industrial <br /> ❑ Soil boring/geoprobe/hydropunch ❑ Landfill <br /> ❑ Other (specify) Shallow Excavation ❑ Other (specify) <br /> 0 Provide a brief description of the proposed activities <br /> Installation of ground water monitoring wells to an approximate depth of 25 feet below ground <br /> surface <br /> Investigation-derived material disposal <br /> Soil stockpiled <br /> Water <br /> Other <br /> III. POTENTIAL HEALTH AND SAFETY HAZARDS <br /> Antic_pated physical hazards Check all that apply <br /> ❑ Heat(high ambient temperature) ® Heavy equipment <br /> ❑ Cold ® Physical injury/trauma resulting from <br /> ® Noise moving machinery <br /> ❑ Oxygen depletion/asphyxiation <br /> ❑ Excavation cave-ins ® General construction physical injury/trauma <br /> ® Falls, trips, slipping ® Electrical hazards <br /> ® Traffic control <br /> ® Overhead hazards ❑ Other (specify) <br /> SSP 911-011 1A <br />