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�s <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Wheel Works —i1' .Is Hazards <br /> Address:420 W.Lodi Ave. i CA 9 24 ®Carcinogens:oil <br /> Contact Person: i Phone No:209 339-9500 ❑Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection:9-8-09 ❑Explosives: <br /> ®Flammables:oil <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 PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: <br /> Tank Age: 1. Monitoring Equipment(note:Monitoring instruments most be used for all <br /> : <br /> Tank Content: 8 operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation:Tires&auto service ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify, <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> ®Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: OF(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ®Noise Sources:traffic ❑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 /> El ❑APR ❑SCBA <br /> etc ), <br /> ❑Confined space entry:(explosions): <br /> A/P cartridge: <br /> ❑Heavy equipment(physical injury&mum 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:January 8.2010 <br /> ❑Other/Unknown(specify): , ��( <br /> Plan Approved by: W ry Date: 1"-((a- t G <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,tenain,etc.) <br /> EH 23081(12/1712002) <br />