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SITE HEALTH AND SAFETY PLAN PART GENERAL SITE INFORMATION 1. Site Name: Quality Auto Repair Address: 1246 E Harding Way, St( Contact Person: Allen Tavakoli Phone No: 476-8322 Sweeps Number: Proposed Date of investigation/inspection: 2. Description and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ Installation of Borings / Monitoring Wells. ,P24azardous Waste 3. Specific Site Information: Tank No.: Tank Capacity: _ Tank Content: Tank Age: Other: 4. Type of Operation: Auto 5. Release History: �u Evidence of leaks / soil contamination: ❑ YES Z NO Documented Groundwater contamination: ❑ YES O Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Hear or Cold Stress: °F (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): andling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): vy equipment (physical injury & trauma resulting from moving equipment): ❑ Other, specify Anticipated Biological Hazards: ❑ Snakes ❑ hisects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (12/17/2002) PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards Carcinogens: waste oil el -Corrosives: ❑ Dusts: ❑ Explosives: ammables: ❑ Inorganic Gases: Pletals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ❑ D ❑ Hard Hat. ❑ Safety Glasses/goggles. ❑ Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ❑ Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: ❑ Safety vest. ❑ Two-way communication. PART IV - PLAN APPROV Plan Prepared by: Date: Plan Approved by: Date: