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SITE HEALTH AND SAFETY PLAN <br /> PART I PARTE[ <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Guzman's Auto Repair 1. Chemicals Hazards <br /> Address: 1037 Yosemite Avenue &�yJCarcinogens: <br /> L� <br /> Contact Person:Jose Lopez Phone No: Corrosives: <br /> Sweeps Number: VDusts: <br /> Proposed Date of investigation/inspection:8/31/07 ❑��/Explosives: <br /> LVA Flammables: <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. <br /> ❑Oxidizers: <br /> ❑ ank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> Hazardous Waste 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 /> - <br /> [I Combustible Gas/Oxygen Meer. <br /> �t <br /> 4. Type of Operation: i'I b ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of Jenks/soil contamination: [I YES ❑NO [I Other,specify. <br /> Documented Groundwater contamination: C]YES ❑NO If monitoring instruments are not used,rationale or activity/men 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 /> ❑Hear or Cold Stress: OF(high ambient temp.) ,❑,�Safety Glasses/goggles. <br /> ElNoise Sources: Ly'Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: <br /> E]Flame retardant coveralls. <br /> ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> EI,/Handling and Transfer of a Hazardous Substance:(fire,explosions, El[3RRespirator: ❑APR El <br /> etc..): <br /> EfConfined space entry:(explosions): A/P cartridge: <br /> Ly Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): OXwo-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: p^ AI !r <br /> ❑Snakes Insects ❑Rodents El Poisonous Plants Plan Prepared by: 'r r " �^ Date: <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(12/172002) <br />