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0 <br /> CORNERSTONE <br /> COCO <br /> EARTH GROUP <br /> SITE HEALTH AND SAFETY PLAN <br /> All of the following questions must be completed. This plan may only be used for Level C and D levels of personal <br /> protection. If a different Site Health and Safety Plan is submitted, that plan must include the follo4ling minimum <br /> information. This plan may NOT be used for confined-space entry. <br /> I. GENERAL SITE INFORMATION <br /> Site Name:Project Sierra <br /> Site Address: 2801 West Louise Avenue <br /> Site Contact Person: Ross Timline Phone: 650-218-3766 <br /> Client's Site Number: Proposed Date(s)of Site Work: December 5,200 <br /> H. DESCRIPTION OF INSPECTION ACTIVITY <br /> Purpose of Activity Type of Site <br /> ® Soil Boring/Monitoring Well Installation ❑ Gasoline Storage(Service Station/Terminal) <br /> ❑ Operation&Maintenance ❑ Industrial <br /> ❑ Construction ❑ Commercial <br /> ❑ Air/Soil/Groundwater Sampling ❑ Residential <br /> ❑ Other(specify): ❑ Other(specify): <br /> Provide a brief site history,estimated concentrations of chemicals of concern,and proposed activities: <br /> See work plan <br /> Describe how investigation-generated materials will be stored and disposed: <br /> Soil: <br /> Water: See work plan <br /> Other: <br /> III. POTENTIAL HEALTH AND SAFETY HAZARDS <br /> Identify potential hazards(check all that apply)and describe safety protocol: <br /> ❑ Heat(high ambient temperature) <br /> ® Fire Prevention/Protection <br /> ® Cold <br /> ® Noise <br /> ❑ Oxygen Depletion <br /> ❑ Excavation/Trenches <br /> ® Overhead Utilities <br /> ® Below-grade Utilities(during excavation) <br /> ❑ Cave-In/Collapse of Sidewall(during excavation) <br /> ® Falls,Tripping,Slippery Surfaces <br /> ® Heavy Equipment(from lifting,dropping,rolling) <br /> ® Overhead Equipment <br /> ❑ Vehicular Traffic <br /> ❑ Pedestrian Traffic/Access to Work Area <br /> ❑ Other(specify): <br />