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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:AnnorStruzx 1. Chemicals Hazards <br /> Address:500 S Beckman Rd.Lodi.CA 95240 ®Carcinogens: oil paint solvents diesel fuel <br /> Contact Person:Aaron Allen No:631745-4651 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:2-7-11 ❑Explosives: <br /> ❑Flammables:oil,diesel fuel <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. p�Other:®HW inspection PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions we provided) <br /> Other <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:i� tome ■ pn QvIt10 v ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: tt1 a <br /> Aw <br /> Evidence of leaks/soil contamina' n: 1 ]YES [INO C]Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> 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 /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ®D <br /> Physical Concerns:(check all that apply&describe) <br /> Hard Hat. <br /> F1Heat or Cold Stress: °F(high ambient temp.) ® <br /> ®Safety Glasses/goggles. <br /> ®Noise Sources:traffic <br /> ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ®Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): <br /> ❑Confined space entry:(explosions): ❑Respirator: ❑APR ❑SCBA <br /> ®Heavy equipment(physical injury&trauma resulting from moving A/P cartridge: <br /> equipment):fork lifts manufacturing eauivement ®Safety vest. <br /> ❑Other,specify ❑Two-way,communication. <br /> 7. Anticipated Biological Hazards: PART IV-PLAN APPROVAL <br /> ❑Snakes ®Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Prepared by:Aris Cacaoit Date:Feb 4 2011 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: 1- Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23091(12/1712002) <br />