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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:Payless Foreign Car Repair 1. Chemicals Hazards <br /> Address:26 N Cherokee Ln#B Lodi CA 95240 ®Carcinogens:OIL <br /> Contact Person:Frank Pelco Jr. Phone No:209 334-3112 ❑Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection:June 4.2009 ❑Explosives: <br /> ®Flammables:011, <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. <br /> ®HW inspection <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> r� ��� <br /> C1 Combustible Gas/OxygenMeter. <br /> 4. Type of Operation:00111 tzCAuuY El Detector Tubes(Specify). <br /> ❑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 /> Level of Protection: [IA ❑B E]C Z D <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: IF(high ambient temp.) <br /> ®Noise Sources:traffic ®Steel t eanshoes or boots. <br /> [I Oxygen Deficiency: E] r <br /> Flame retardtardantt coveralls. <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, Elf ❑ Respiespirator. ❑APR [ISCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety 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 Cacaoit Date:June 4.2010 <br /> ❑Other/Unknown(specify): ��,�( <br /> Plan Approved by: 1/"- 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 />