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u �1 <br />SITE HEALTH AND SAFETY PLAN <br />PARTI PARTII <br />GENERAL SITE INFORMATION , EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: aR 1�A(1u, 1. Chemicals Hazards <br />Address: 8932 E Hwy 12 Victor. X A253 ® Carcinogens: oil coolant <br />Contact Person: George William B No: (209) 368-9864 ®Corrosives: lead acid batteries <br />Sweeps Number: ❑ Dusts: <br />Proposed Date of investigation/inspection: 5-14-12 ❑ Explosives: <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. ❑ Re -excavation. <br />❑ Installation of Borings / Monitoring Wells. <br />® HW inspection ❑ Tiered Permit inspection <br />3. Specific Site Information: <br />Tank No.: <br />Tank ( <br />Other: <br />Tank Capacity: <br />Tank Age: <br />4. Type of Operation: welding shoo <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />® Heat or Cold Stress: 90 OF (high ambient temp.) <br />® Noise Sources: traffic, <br />Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />rt' ) <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />❑ Snakes ® Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />® Other: contaminated absorbent <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />❑ Two-way communication. <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: Aris Cacaoit Date: 5-14-12 <br />Plan Approved by: 12 1 Date: S <br />