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HomeMy WebLinkAbout4647 WILSON Road_UST REMOVAL 1.7.11HOODS A ARMS - SPRNKLER SYSTEMS SPRAY BOOTH AST UST Permit-No. Permit No. Permit No. Permit No. Permit No. Permit No. File Number: ,��� Address: wlea 4f 7 W� C.So� tact. Bakersfield, CA 933 Date Received: /-7-1/ Business Name: SYSTEM: BUILDING SQUARE FEET: INSPECTION LOG New Mod. ❑ ❑ Commercial Hood System Building Sq. Feet: Date Time ❑ ❑ Fire Alarm System Calculation Bldg. Sq. Ft: I. ❑ ❑ Fire Sprinkler System 2. ❑ ❑ spray Finish System 3. ❑ ❑ Aboveground Storage Tank 4. ❑ ❑ Underground Storage Tank minor Signature modification Underground Storage Tank removal Un rground Storage Tank Signature ❑ ❑ Other: Comments: s3 S i�w��m �. ti � -_ _.... �. Message Page 1 of 3 Howard Wines - RE: 7-11,4647 Wilson - From: "Jason Smith" <jsmith @wpsac.com> To: "Howard Wines" < Hwines @bakersfieldfire.us> Date: 1/27/201112:29 PM Subject: RE: 7 -11, 4647 Wilson CC: "Cheryl McPeek" <cmcpeek @wpinc.com> Great, thank you. Please put our PO on the credit #N11156 referencing check number 25811. Also, you mentioned that the previously abandoned tank was filled with concrete slurry. a think it was you that mentioned that) Will we have the option to remove'the other 2 tanks, leaving the third one in place since pulling a 10,000 gal. steel tank full of concrete is not likely. I just want to see where you stand. I have forwarded that info to our consultant and they are checking more into it. I know you guys will be in the Cupa conference next week so I hope to get a game plan for the tank pull next Friday. Thanks Jason Smith Operations Manager (N) JsmithCcDwpsac.com 30 Main Ave, Suite 5 Sacramento, CA 95838 Office- 916- 646 -9680 Cell- 916- 834 -5712 - - - -- Original Message---- - From: Howard Wines [mailto :Hwines @bakersfieldfire.us] Sent: Thursday, January 27, 2011 12:03 PM To: Jason Smith Cc: Cheryl McPeek Subject: RE: 7 -11, 4647 Wilson You are correct. I will issue Wayne Perry, Inc. a $573 refund for the previously abandoned 3rd tank. Howard H. Wines, III Professional Geologist 7239 Prevention Services Director Bakersfield Fire Department Email:.HWines@BakersfieldFire.us Office: (661) 326 -3659 > > > "Jason Smith" <jsmith @wpsac.com> 1/27/201111:41 AM > > > O, sorry one more thing. I sent a check #25811 in the amount of 1,719.00 for the permit per planning's quote, I was told 573.00 a tank (3 tanks) which is what the total was but the permit /receipt you sent me attached only adds up to 1,146.00. Will I be receiving a credit? I don't know if the previously abandoned tank in place is the reason file: //C:\ Users \hwines \AppData\ Local\ Temp\XPgrpwise \4D416523COBcobpo 1100179696... 1/27/2011 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page -of _ TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 0 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ® 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason -for local use only) (Specify reason -for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) FACILITY ID: 1 7- Eleven #16549 3 1 LOCATION WITHIN SITE (optional) 431 4647 Wilson Rd., Bakersfield a/�� klvll ld(11g :ll r'M10 � •�: :t: i.. TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes N No 434 3 abandoned in pi ace Joor If "Yes', complete one page for each compartment. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 435 NUMBER OF COMPARTMENTS 437 10/1984 10,000 ADDITIONAL DESCRIPTION (For local use only) 438 IL-TAN!CCONTOM ( TANK USE 439 PETROLEUM TYPE 440 ® 1. MOTOR VEHICLE FUEL ❑ 1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (It marked complete Petroleum Type) ❑ 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ 1c. MIDGRADE UNLEADED • ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE Gasoline (Includes Used Oil) ❑ 95. UNKNOWN TYPE OF TANK 1. SINGLE WALL L3 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ® 2. DOUBLE WALL ❑ 4. SINNLE WALL IN VAULT E399. OTHER TANK MATERIAL - primary tank 1. BARE STEEL 3. FIBERGLASS / PLASTIC 5. CONCRETE 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W /FIBERGLASS ❑ 8. FRP COMPATIBLE W/ ❑ 99. OTHER REINFORCED PLASTIC (FRP) 100% METHANOL TANK MATERIAL - secondary tank 1. BARE STEEL 3. FIBERGLASS/ PLASTIC 5. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL 19 4. STEEL CLAD W /FIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER REINFORCED PLASTIC (FRP) W /100 %METHANOL [15. CONCRETE ❑ 10. COATED STEEL TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 448 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑ 99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE,INSTALLED 448 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER (Check one item only) ❑ 2 SACRIFICIAL ANODE I (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all ® 1 SPILL CONTAINMENT 2004 that apply) ❑ 1 ALARM ® 3 FILL TUBE SHUT OFF VALVE 0 2 DROP TUBE 2004 ❑ 2 BALL FLOAT ❑ 4 EXEMPT ® 3 STRIKER PLATE 1984 2004 s >: :: MNE aAtlor%aiBia ti.ttnatae.141tJS F::s; >: �::.,:::`:;,: . ". IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one Item only) ❑ 1 VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE ® 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING + (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER ESTIMATED DATE LAST USED (YR/MO /DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE ass REMAINING TANK FILLED WITH INERT MATERIAL? 457 allons ❑Yes ❑ No UPCF (1/99 revised) Formerly SWRCB Form B ; 0 6 0576 BFD HAZ LSAT DIV 121002- Permit Nate -a.��j CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326 -3979 PERMIT APPLICATION FOR REMOVAL OF AN UNDERGROUND STORAGE TANK SITE 16 Sy ��_ . _~ -`7 / ADDRES� 416 V7 6vicsp,v .Od ZIPuCQpE 93W/ APN FACILITY ;,TAME Soy7WtAe►0/D -7-11 CROSS STREET 4, Trt TANK OW NER/OPERATOR 5jp. MD H PHONE NO. ' r G MAILING ADDRESS ! 0 --? 0 S w �� r y p,Z A,pAV I 3 ZIP 7 LZ CON-1'RAC:TOR INFORAIATIQN COMPANY K-1M C 01 Af00 -4 AL PHONE NO. µ2S 3SS -2 LL LICENSE NO. ADDRESS 12-5Z! 8v fA9,v Oa- CITY u Liles VA ZIP_ L7 INSURANCE CARRIER C4 c_ S WORKMENS COMP NO. PRELIMINAR Y A SESSLWENT IN ON COMPANY XT 6-Roulp, PHONE NO.6 (6) 2EQ ZI qPE ICENSE NO. UIVk.Npwri ADDRESS -- DO-C 10CT CHICIMp F+w y CITY EnfvcpAo ZIP sl INSURANCE CARRIER WORKMENSCOMPNO. UMItwOwP-1 TANK CLEANING INFOR ATION, rr COMPANY _j'Ef'VtCO PHONENOi "�-) ADDRESS I V 1 C, STUeT CITY A4oOiF& -M EAIi F Z[pp 3S/ WASTE TRANSPORTER IDENTIFICATION NUMBER _ NAME OF RINSATE DISPOSAL FACILITY ADDRESS CITY ZIP FACILITY IDENTIFICATION NUMBER TANK TRANSPORTER INFQBMI N COMPANY h 1 14 PHONE NO. LICENSE NO, ADDRESS jpq CITY ZIP TANK DESTINATION TANK INFORMATION CHEMICAL DATES CHEMICAL TANK NO. AGE VOLUME STORED STORED PREVIOUSLY STORED for AHlad l.l+c I)n APPLICATION DATE '1111: AN'LICANT IIAS RI DIVED. UNDRIU I'ANDS, AND WU.I. COMPLY Wf171'I IM. AITACIIED CON01110N.4 O TIII.s 1T ItMIT ;AND ANY t AI IER - 'rIWIli, LOCAL A&D I"IM _RAL REGULATIONS. 1111:1 RN'M I JAS 1i1:1:N Cl)MPI ' D HINDER [JENAL YOF PCRAMY. AND TO TIIR 11 -51' 01-* MY KNI)W1.I'IXi16 IS TRllls �- /IJJiXc /��vzSC �v AI'I�Kt IV ' APPLICANT NAMI3 (PRIM) Alfpf ICAN'I' 910NATURE THIS APPLICATION BECOME A PERMIT WHEN APPROVED C/Z O 11/71 dt / 1" F_ " CONSTRUCTION PERMIT Application Number . . . . . Property Address . . . . . . ATN (11 Digits): Application type description Subdivision Name . . . . . . Property Use . . . . . . . . Application valuation . . . . Owner ------------------ - ----- WANG SHUNLI & SHUJAN PO BOX 711 DALLAS TX 75221 BAKERSFIELD FIRE DEPARTMENT .^P� PREVENTION SERVICES E R S F I D 1501 TRUXTUN AVENUE, IT FLR FIRE BAKERSFIELD, CA 93313 'ARTM T � Office Phone: (661) 326 -3979 11- 10000015 Date 1 /11 /11 4647 WILSON RD 441 - 381- 02 -00 -9 FIRE DEPT 0 Contractor ------------------ -- - - -- OWNER ---------------------------------------------------------------------------- Permit . . . . . . UNDGRND STR TANK REMOVAL Additional desc . . Phone Access Code . 1065770 Permit Fee . . . . 286.50 Plan Check Fee 286.50 Issue Date . . . . 1 /11 /11 Valuation . . . . 0 Expiration Date . �------------------------------------- . 7/10/11 --------- Fee summary ------- - - - - -- Charged ---- - - - - -- ---- ------------------ Paid Credited - - - - -- ---- - - - - -- ---- -- ---- - - - - -- Due - - - - -- ---- Permit Fee Total 286.50 286.50 .00 .00 Plan Check Total 286.50 286.50 .00 .00 Grand Total 573.00 573.00 .00 .00 CALL FOR INSPECTION (661) 326 -3979 Please state the Permit Number, the Job address, and the Type of Inspection. Requests for inspections should be made at least 48 hours in advance. DECLARATIONS Permit is issued in accordance with all applicable Federal, State and Local Ordinances. The permittee has properly signed and dated the reverse side of this form. This Permit expires afterl80 days of inactivity. I have reviewed the above application, and find it to be correct/complete. Permittee: Date: HAZARDOUS MATERIALS STATEMENT Yes _ No Will the applicant or future occupant handle hazardous material or a mixture containing a hazardous material equal to or greater than the amounts specified on the list of extremely hazardous substances? See checklist for guidelines. _ Yes _ No Will the proposed building or modified facility be within 1000 feet of the outer boundary of a school? _ Yes _ No Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the Kern County Air Pollution Control District ( KCAPCD) or from the Bakersfield Fire Dept? See checklist for guidelines. Yes _ No I have read the Hazardous Material Guide and KCAPCD Permitting Checklist. I understand my requirements under the Calif. Health and Safety Code Sec. 6.95 and Calif. Govt. Sec. 65850 and the requirements of the City of Bakersfield Fire Dept. regarding hazardous materials. Owner or Authorized Agent. hone No. Date DECLARATIONS: The declarations below are mandated by the State of California under Section 19825 of the Health and Safety Code. LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of the Division 3 of the Business and Professions Code and my license is in full force and effect. Lic. Class Lic. No. Exp. Date Contractors Signature Date OWNER- BUILDER DECLARATION I hereby affirm that under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Sec. 7031.5 Business and Professions Code: Any city or county which requires a permit,to construct, alter, improve, demolish, or repair any structure prior to its issuance also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 commencing with Section 7000 of Division 3 or the Business and Professions Code) or that he or she is exempt there from and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)): I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he or she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such project with a contractor(s) licensed pursuant to the Contractor License Law). I am exempt under Sec. B. & P. C. for the reason Owner Signature I Date WORKERS COMPENSATION DECLARATION I hereby affirm that under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy No. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. Applicant: Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000) IN ADDITION TO COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097 Civ. C.) Lenders Name Lenders Address I certify that I have read this application and state that the information contained herein is correct. 1 agree to comply with all city ordinances and state laws relating to building construction and hereby authorize representatives of the city to enter the above mentioned property for inspection purposes. Signature of Applicant or Agent I I Date UNDERGROUND STORAGE TANKS CONDITIONS FOR ABANDONMENT /CLOSURE /EXCAVATION, REMOVAL, AND DISPOSAL/SOIL SAMPLING, PRELIMINARY SITE ASSESSMENT BAKERSFIELD FIRE DEPARTMENT ✓'� Prevention Services B E R 9 ?-1 D 2101 H Street F�Ra T Bakersfield, 93301 Phone: 661 - 326 26 -3979 •Fax: 661 - 852 -2171 Page 1 of 4 Contractors must have the following information on file in order to obtain a permit: I. Copy of contractor license ."" 2. General liability policy ✓ 6, 3. Workman's compensation policy 4. Site safety plan ✓ 5. International Code Council pocket licenses *Site assessment /sample collection contractor must have a soil sampling and quality control /quality assurance protocol on file.. . GENERAL (REMOVAL) 1. A permit application for an UST abandonment shall be filed and applicable fees paid 5 working days prior to the commencement of work. This permit shall remain onsite during the entire removal process. ■ Permit is valid for 90 days 2. Forty -eight hour advance notice shall be given to the Bakersfield Fire Department Office of 'Prevention Services to arrange an inspection appointment. 1 3. It is the responsibility of the permittee to obtain any permit required by other regulatory agencies (i.e., Building Department and Department of Public Works). 4. Tank Closure activities must follow the Uniform Fire Code and all Federal-and Cal -OSHA regulations. 5. It is .the Contractors responsibility to know and adhere'to all applicable laws. and regulations regarding the handling, transportation, or treatment of hazardous materials. 6. If any contractors other than those listed on permit and permit application are to be utilized, prior approval must be granted by the Bakersfield Fire Department Office of Prevention Services. Deviation from the ' subm.itted application .is not allowed. TANK'EXCAVATION, REMOVAL, AND DISPOSAL 1. Abandonment of tanks..in• place will only be allowed if removal would pose undue risk to ' an existing structure.., .Proof of risk and a work plan /proposal shall be submitted to the Bakersfield Fire Department Office of, Prevention Services for review and approval prior to the commencement of any work activity. 2. Excavation of enough material to expose the top of the tank, removal of contents, high pressure rinsing, and inerting may be done prior to the arrival of the inspector. Tanks may not be removed without an inspector present. Job site safety and assuring all Cal -OSHA regulations are followed is the contractor's responsibility. 4. Excavation, holes, pits, trenches, etc. shall be backfilled immediately to a minimum of 90 percent soil compaction or as otherwise specified by the building official under any separate grading requirements. Any excavations not immediately backfilled upon completion of tank removal and soil sampling shall be properly secured (fenced off) to ensure public safety. FD2091 (Rev 08 /07) Page 2 of 4 UNDERGROUND STORAGE TANKS CONDITIONS FOR ABANDON MENT /CLOSURE %EXCAVATION, REMOVAL, AND DISPOSAL/SOIL SAMPLING, PRELIMINARY SITE ASSESSMENT 5. Any excavated material from the tank pit, piping runs, etc. not used as approved backfill will be properly disposed of, or if left on location will be either containerized or covered with suitable material to prevent the emission of hazardous, noxious, or unpleasant vapors and /or odors. In addition, the material will be properly secured (fenced off) to ensure public safety. 6. Tanks shall be either decontaminated or transported as hazardous waste. 7. A Hazardous Waste manifest will accompany either the rinseate or the tank and shall be present on site and presented upon request. 8. The interior of tank being transported not as hazardous waste (decontaminated) shall have a lower explosive limit (LEL) 'of no greater than 5 percent immediately following cleaning and prior to the introduction of carbon dioxide (CO Z). ■ The contractor shall' certify on the inspection form that the cleaning process was properly conducted and the LEL results did not exceed 5 percent. 9. The decontaminated tank shall be 'inerted with the introduction of CO2:in the form of dry ice or from canisters. a. A rate of 20 pounds of dry ice to 1,000 gallons of tank capacity, or the corresponding weight of CO2. b. If canisters are used, they shall be bonded to the tank. c. A receipt for the CO2 shall remain on site and presented upon request. 10. Prior to the removal of a decontaminated tank, the LEL level will be no greater than 5 percent and the oxygen'level will be no greater than .9 percent. 11. No man -ways may be cut into tanks unless an, inspector from Bakersfield Fire Department Office of Prevention Services is present. . UNDERGROUND STORAGE TANK ABANDONMENT IN -PLACE The following requirements apply to in -place abandonment of underground storage tanks. 1. All conditions noted on the permit are to be strictly followed, including but not limited to: a. Notification of the regulatory agencies involved b. Posting of the permit on the job site.in clear view c. Approval from Office of Environmental Services is to be granted for any changes in the original application before beginning any work 2. The preliminary site assessment is to be completed, results. submitted to Office of Prevention Services, and approval granted before any of the following required steps are taken. 3. All dispensers and piping, with the exception of the vent line, are to be removed for proper disposal prior to cleaning the tank. 4. The interior of the tank should be water- or steam - rinsed under pressure or the equivalent to remove residual hazardous wastes. Documentation of the rinsing and removal of the rinseate is to be made; all such wastes are considered hazardous wastes unless proven otherwise and shall be transported under manifest. A copy of the manifest, signed by the disposal facility, is to be provided to Office of Prevention Services within 14 days of rinseate removal. 5. The contractor decontaminating the tank is to have a copy of their decontamination procedure on file with Office of Prevention Services. FD2091 (Rev 08/07) UNDERGROUND STORAGE TANKS CONDITIONS FOR ABANDONMENT /CLOSURE /EXCAVATION, REMOVAL, AND DISPOSAL/SOIL SAMPLING, PRELIMINARY SITE ASSESSMENT Page 3 of 4 6. By use of an explosivity meter that measures LEL, the contractor decontaminating the tank is to document the complete removal of sludge and waste. A maximum 5 percent LEL reading is to be achieved for the tank Jo be decontaminated and no longer considered a hazardous waste. The contractor should have documentation of training in the use of the explosivity meter on file with Office of Prevention Services and a record of monthly equipment calibration on site. 7. The ends of the tank are to be exposed unless they are under a building. 8. The fill drop tube is to be removed. The vent line should be left attached and open during the entire abandonment process. 9. The tank should not be filled or punctured until the inspector is present. Office of Prevention Services requires 2 working days notification. Only excavation to expose the top of the tank, high pressure rinsing, and removal of flammable /combustible liquids by pumping and inerting as described in #10 below may be done without an inspector present. 10. The tank should be inerted before filling by use of an inert gas, such as CO2. The oxygen level will be verified by Office of Prevention. Services meter to be below 12 percent. Example: Use of either CO2 or dry ice - 2 pounds per 100 gallons of tank capacity of 20 pounds per 1,000 gallons of tank capacity. Note: Dry ice should be placed in the tank at least 4 hours before Office of Prevention Services inspection. Warning: If a liquid or gas inerting agent is to be used, the dispensing device shall be electrically grounded to the tank. 11. The tank shall meet the following purging and /or inerting conditions: a. Any remaining liquid shall be pumped from the tank before purging so that less than 8 gallons of liquid remain in the tank. b. The tank shall be purged through a vent pipe that discharges at least 10 feet above ground level. C. No emission shall result in any odors detectable at or beyond the property line. d. No emission shall endanger the health, safety, comfort, or repose of any person.. e. The vent lines shall remain attached to the tank until the inspector arrives to authorize the filling. 12. All caps in the top of the tank are to be removed. If the caps at the ends of the tank cannot be removed or do not exist, the tank is to be punctured in a safe manner that reduces deformation. At least 2 holes at opposite ends of the tank are required before the tank filling process can begin. 13. The tank should be filled with a 2 -sack concrete mix. Only enough water to allow smooth flow and good, compaction should be added to the concrete mix. The filling process is to continue until the material flows from all holes in the top of the tank. Care is to be taken in the filling process to prevent voids from occurring. 14. The vent lines are to be removed and properly disposed of and the tank capped. 15. The backfill over the tank should be compacted to Public Works standards. SOIL SAMPLING /PRELIMINARY SITE ASSESSMENT 1. Soil samples shall be obtained under the direction of a professional engineer, geologist, or authorized representative of a State- approved laboratory. 2. Samples shall be collected at a minimum from depths of 2 and 6 feet below the tank bottom, dispensers, and product lines, and from the following locations: a. Tanks less than 1,000 gallons: from the center of the tank b. Tanks 1,000 - 10,000 gallons: one -third of the way in from each end C. Tanks greater than 10,000 gallons: from center and one -fourth of the way in the end of the tank d. Below all dispensers e. Piping: every 20 feet and /or at connections, joints, bends, etc FD2091 (Rev 08/07) UNDERGROUND STORAGE TANKS Page 4of4 CONDITIONS FOR ABANDONMENT /CLOSURE /EXCAVATION, REMOVAL, AND DISPOSAUSOIL SAMPLING, PRELIMINARY SITE ASSESSMENT 3. Any area of obvious contamination of likely areas of contamination may be required to be sampled. 4. All samples shall be analyzed bya State - certified laboratory. 5. Soil samples shall be analyzed for all known and suspected substances to have been stored in the tank. Additionally, methyl tertiary butyl ether (MTBE) shall be analyzed in all soil samples taken from beneath tank - systems which contained any motor vehicle fuel. 6. All samples will be accompanied by a chain -of- custody sheet. 7. A soil sample report/preliminary assessment shall be submitted to Office of Prevention Services within 5 days after results have been received and shall contain at a minimum the following information: a. Name and location of where tanks were disposed b. Name and location of where rinseate was disposed C. A signed copy of the Hazardous Waste Manifest d. A tank disposal receipt from the scraping facility e. Copies of all lab data sheets and chain -of- custody documentation f. A plot plan showing the location of buildings, tanks, piping runs, dispensers, and all sample locations with corresponding identification numbers and depths FD2091 (Rev 08/07) 1. 1 .. ' BAKERSFIELD FIRE DEPARTMENT UNDERGROUND STORAGE TANK . Services R 3 P I n 2101 H Street PERMIT APPLICATION PtRe Bakersfield, CA 93301 FOR REMOVAL OF AN UNDERGROUND STORAGE TANK ARI'm T Phone: 661 - 326 -3979 • Fax: 661- 852 -2171 Page 1 of 1 Permit # THIS APPLICATION WILL BECOME A PERMIrT WHEN APPROVED FD2088 (Rev 03/08) 2m I SITE INFORMATION SITE *165W ADDRESS �l4qw _. IPCODE 5e::14? FACILITY NAM(/ _/ L CROSS S REET o ' TANKOWNER/OPERAT - "�f PHONE # APN # MAILING ADDRESS / CITY 7- ZIP CODE / CONTRACTOR INFORMATION COMPANY / /� A� / [sJ ,T • PHONE # 571 q . ( LICENSE # _ ADDRESS CTTY ZIP�ODE •- �"� INSURANCE CARRIER WORKMENS COMP # PRELIM ARY ASSESSMENT INFORMATION I COMPANY G PHONE _ �D d LICENSE T ADDRESS CITY ' - ZIP CODE INSURANCE CARRIER , jay !A7 R / WORKMENS COMP # �� TANK CLEA ING INFORMATION COMPANY PHONE # , y h [/ LICENSE # ADDRESS y CITY /, ZIP CODE C INSURANCE CARRIER U • ` WORKMENS COMP # J� GJ WASTE TRANSPORTER ID # ��� CI I N ME OF RIN DISP L FACILITY ADDRESS Ilipcnwaa TANK TRANSPORTER INFOR ATION COMPANY G L / PHONE # LICEN E # O ADDRESS/;5 CITY ZIP TANK DESTIN O� G TANK IN ORMATION TANK # AGE VOLUME CHEEMICAL STORED DATES STORED . CHEMICAL PREVIOUSLY STORED L 112,ZWE Q FOR OFFICIAL USE ONLY APPLICATION DATE FACILITY # # OF TANKS FEE $ THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPROVED BY APPLICANT NAME (PRINT) f APPLI NT SIGN THIS APPLICATION WILL BECOME A PERMIrT WHEN APPROVED FD2088 (Rev 03/08) 2m I Post•it"routing request pad 7684 �.o ROUTING - REQUEST Please ❑ READ To ❑ HANDLE ❑ APPROVE boo i<S i" and ❑ C Sc� '.., rid r CC21, FORWARD l ❑ RETURN ❑ KEEP OR DISCARD ❑ REVIEW WITH ME Date From i FACILITY BAKERSFIELD FIRE DEPARTMENT Prevention Services U UNDERGROUND STORAGE TANS ADDRESS s S R 9 P �' n 2101 H Street ��_� F/RR Bakersfield, CA 93301 INSPECTION FORM OWNER /� A T Phone: 661 - 326 -3979 . Fax: 661 - 852 -2171 FOR TANK REMOVAL ,y Page 1 of 1 FACILITY ADDRESS Iv.� OWNER /� PERMIT TO OPERATE # ,y CONTRACTOR C"TA ERSON ? , LABORATORY / e # OF SAMPLES 7C , G AT ST M ODOLO 7 / PRELIMINARY A SESSMENT COMP Y. CONTACT PERSON CO RECEIPT LEL % 02 % PLOT PLAN I.ICi Ixf /`< CONDITION OF TANK CONDITION OF PIPING , CONDITION OF SOIL COMMENTS u DATE INSPECTOR NAME SIGNATURE FD2089 (Rev 08/07) ACoR °® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1/6/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy((es) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Patriot Risk and Insurance Services License #OG55454 CONTACT JOSie GaV].ere3 NAME: PHONE Ext, (949)486 -7900 FAX No: (949) 466 -7950 ADDRESS: PRODUCER 00000260 8105 Irvine Center Dr. #400 INSURERS AFFORDING COVERAGE NAIC# Irvine CA 92618 INSURED INSURERA:Chartis Specialty Insurance 26883 INSURERBAllied Insurance X COMMERCIAL GENERAL LIABILITY _ INSURER C:SeaBri ht Insurance Company 15563 Wayne Perry, Inc. INSURER D: DAMAGE TO RENTEU PREMISES Ea occurrence 8281 Commonwealth Ave. INSURER E: CLAIMS -MADE OCCUR • INSURER F: PROP1665078 Buena Park CA 90621 CAVFRAl2FiR ` CFRTIFICATF NIIMRFR -10 -11 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L SI ' TYPE OF INSURANCE D S BR POLICY NUMBER MM//DDDY EFF MM/DD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEU PREMISES Ea occurrence $ 100,000 A CLAIMS -MADE OCCUR PROP1665078 2/31/2010 2/31/2011 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 X $5,000 BI &PD.Deductible - X' Per Occurrence GENERAL AGGREGATE S-. -2,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS - COMP /OPAGG $ _'2i000,000 $ X POLICY PRO- LOC ' B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS - CP7803768554 2/31/2010 2/31/2011 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) E BODILY INJURY (Per accident) E X SCHEDULED AUTOS HIRED AUTOS PROPERTY (Per accident) DAMAGE $ Uninsured motorist property $ X NON -OWNED AUTOS Uninsured motorist combined S 11000,000 X UMBRELLA LIAB :' X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ '5,000,'000 EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ ' $ RETENTION S 10,000 ROU7340721 2/31/2010 2/31/2011 L. RKERS COMPENSATION D EMPLOYERS' LIABILITY YIN ,PROPRIETOR/PARTNER/EXECUTIVE X WC STATU- OTH- E.L. EACH ACCIDENT $ 1,000,000 CER/MEMBER EXCLUDED? ofMandatory In NH) NIA 81111086 /1/2011 /1/2012 E.L. DISEASE.- EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 11000,00 A Pollution & Professional. ROP1665078 2/31/2010 2/31/2011 Limit: $1,0001-000 liability Each Claim DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Proof /Evidence of Insurance Proof /Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gary Hamilton /JOSIEG A ACORD 25 (2009/09) ©1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (2oo906) The ACORD name and logo are registered marks of ACORD =� Pursuant to Chapter 9 of Division 310 the :, Business, and - Professions Gode a.nd'the Ru[es:and Regulations of, the Contractors State license "Board, ; the ,Re istrar af.Contractors does hereby Issue'.this.licen'se to UVAYIUE'PERR'Y INC +r w fi License .Ntamber.°S00345 rx T-� _ 'Y -�4.. to engage in the business or actin fhe.capacit of a contractor , i i n in the:folfowin cla`isif cat s ^A1� ,h` \ \ . rod.. � • \ .. -, ' .y • ._ , =� {'. � ; � « _ _- �' , ,..., ,, N .., ..: � , ._ . - d. ,> D40 SERVICBSTATION. EOUIPMENT,AND'MAINTENANCE i "= -HAZARDOUS BUBSTANGES REMOVAL ,A _ - Witness myvhand and seal this`day, 4a c` -ar O_ ctober -6, 2010 =` _ rC,• \i - Y, \,J���,,.�.� a._,C'' ,n „ \:, .-$; .,\,”, ..�,'v.. ,v.'. ,�'L��ux= �i`if "9 •'. \. \:,\ Issued Noveri�ber,22, 1�974.�'�`��, v ,�,y 4 v: CERTIFIED COPY �'t t James Miller` - - Stephen P. Sands, " This liceriie is the property of the Registrar of :,Contractors; - -.Board Chair., _'. " �.;- • °:�" : Rn istrar�of Contractors 3vx,; a �,.�" = is riot trarisfe�rabie; and shall.be returned to the Registrar g 'upon demand when suspended, revoked, or invalidated - "` , "ar '.reason. It becomes void if not renewed. - - ` or y .. r 13L -24 (REV. 12 -07) OSP 07 105460 ` w - � - • NO: y \ \ ® � AUDR 504276 ' a 1 Name: DON BAUGHN Date: 5/13/2010 ;;.:...: . Address: 7941 DOMINION WAY Brth'Date;: 1/6/1966 _ ..........:::.. ELVERTA CA 95626 +k • EXAMINATION RESULT:.::_?AS.S> Congratulations! You have passed the above named examination: °: Your. -Your. llef card: will be forwarded fo : _ "' you by ICC within six weeks from the last day of the month in which you tested. This. certificate is current for two years. You; may request a wall certificate from ICC as well. Throughout 2010,.'this :.certificate will be provided'at V* no cost to:you, if you request it within 90 days of your exam. Only one wall °certiiiioate per exam passed; will be provided to you at no charge. For more information on request !n.g•a..:wall.certificate, go to :., :, ` www.icc : afe.orq /exams. Wis �exfreriiely important that jiou.notify Pearson VUE and ICC of any changes in name an address'fo avoid�the;possibility of your wallet card and /or certificate not being:received':'f?.lea,' contact Pearson. VUE at 800:- 275 -8301 andACC. at certexam @ iccsafe.org with changes to your-h-,,. e and address "(name <= ' changesmay require additional documentation). There may be an adtlit!onal:.f;= ifa certification is re- issued due to a misspelled -name or incorrect address. I HE A ,RED BACKGROUND'THAT CHANGES COLOR GRADUALLY AND EVENLY FROM DAR �;:,.,::..QST Dedommissioning XX434: 47593". R AREAS BOTH LEFT AND coft Candidate ID: ,RED BACKGROUND'THAT CHANGES COLOR GRADUALLY AND EVENLY FROM DAR �;:,.,::..QST Dedommissioning XX434: 47593". R AREAS BOTH LEFT AND Site °Safety and:Healfh Plan, r 'rt Site, Safe and Health.Plan !•1:fSrSlR� 7- Eleven # RD54 4647 Wilson Rd. Bakersfield, Ca 93309 January 7, 2011 nMu9La Incident Free Operation Page 1 of 68 1 Site Safety�_and-Itealth',Plan APPROVALS Wayne Perry, Inc. - Office Administrator Reviewed and approv y 9 J12 son SM- h ayne Perry, Inc., `- 7-1t Date l _ Incident Free Operation Page 2 of 68 Site Safety and Health Plan - EMERGENCY CONTACTS In the event of any situation or unplanned occurrence requiring outside assistance or support services, the appropriate contact(s) from the list below should be made. The Field Team Leader will have a radio or a mobile phone. Field workers' names and cell phone numbers will be recorded on Page 5 of this Health and Safety Plan, "Project Contacts." In addition, cell phones should be programmed with important emergency phone numbers for easy access. Ambulance/Fire /S.ecurity Emergency .............:....... ......................:........ ............................911 Good Samaritan Hospital ........................... ............................... ...........................661 - 398 -1800 Chem -tree (Emergency Chemical Spill Response Information) ....................800 - 424 -9300 Wayne Perry Emergency Contact Service ....................... ............................... 800 - 883 - 0352• Wayne Perry Medical Records ................ ........ ........................ ...........................800 - 883 -0352 Incident Free Operation Page 3 of 68 Si te Saf ety alt aid Heh Plan " '''� NEAREST EMERGENCY ROOM Good Samaritan Hospital — Southwest 5101 White Lane Bakersfield, Ca 93313 (661) 398 -1800 4647 Wilson Rd Bakersfield, -CA 93309 1. Head west on Wilson Rd toward Stine Rd 2. Take the 2nd left onto New Stine Rd 3. Continue onto Stine Rd 4. Turn right at White Ln 5. Make a U -turn at Grissom St 5201 White Ln Bakersfield, CA 93313 0.2 mi 0.3 mi 0.7 mi 0.3 mi 289 ft Incident Free Operation Page 4 of 68 Site Safety and Healt>i Plan °5 r l Incident Free Operation Page 5 of 68 Site�Safet� and UeAth:Plan PROJECT CONTACTS Jason Smith Project Manager 916.834.5712 Richard S. Allen, MBA, REHS WPI QSE Manager Corporate Health & Safety Officer. 714.618.7957 (cell) Incident Free Operation Page 6 of 68 TABLE OF CONTENTS APPROVALS------.—.—.-----.----_-.-.--------.--.---.---_---_--.-2 EMERGENCY CONTACTS -------.—__-.------..--.---.-.---.--_--.---`—..3 ^ � ` NEAREST EMERGENCY ROOM .......................................................................................... 4 ...'..'..................'...................................'..'...... ..........~....'........'.... 6 PROJECT CONTACTS ' � TABLEOF CONTENTS ----''---.--- ............................................................................. � � � ^ ' SECTION l PURPOSE AND POLICY .-.---------------..—.----_---_----_...l0 ` - 1. 1- .--_--..----_----_-'�-----.—..---_--._.-l0 l�2 / -_-~~^-~~__----_-~.,,~^_._--.—_---_--.-.--_--.—.—.- lO � 1'3} MODIFICATIONS TO THE SSHP ............................................ 10 � 1/4 STOP WORK AUTHORITY -'..-----_-_-_-_.---_-------'ll ' . l.5 / -�--�--- ' }l � SECTION 2SITE DESCRIPTION AND SCOPE OF WORK ............................................. l2 2.1 SITE DESCRIPTION -------_------_--_---..---.---.--.l% 2.2 SITE MAP ............................................................................................ l2 ` 2.3 SCOPE OF WORK ............................................................................... l2 � SECTION 3 PROJECT TEAM ORGANIZATION AND RESPONSIBILITIES .-----.. l] � 3.1 SITE SAFETY AND HEALTH OFFICER .......................................... 13 3.2 FIELD WORKERS ................................................................................ l4 � 3'3 OTHER CONTRACTORS AND SUBCONTRACTORS ................... 14 � SECTION TRAINING AND ME ................ 15 � 4'1 GENERAL TRAINING ......................................................................... l5 � � 4.2 TRAINING ................. ............ '................................... l5 � 4.3 MEDICAL MONITORING --_-_----_..--_-_-.--_---_---' 16 SECTION 5 SITE HAZARD ANALYSIS ............................................................................. 17 5.1 CHEMICAL HAZARDS ...................................................................... l7 5.2 HAZARDS ............................................................ l8 Table5-1 Safety Hazards .................................................................................................................... l8 Table5-2 'Physical Hazards ................................................................................................................ l8 � Table 5-3 Biological Hazards ............................................................................................................. l8 ` 5'3 HAZARD ANALYSIS AND MITIGATIONS lBY TASK .................. 19 Incident Free Operation Page 7 of 68 Suet,:Safety� arnd °HealtIfTlan � �' � . � 6.1 GUIDELINES FOR PRE - EMERGENCY PLANNING AND TRAINING............................................................ ............................... 20' 6.2 EMERGENCY RECOGNITION AND PREVENTION ...................... 20 6.3 PERSONNEL ROLES, LINES OF AUTHORITY, AND COMMUNICATION PROCEDURES DURING AN EMERGENCY 21 6.4 EVACUATION ROUTES AND PROCEDURES, SAFE DISTANCES, AND PLACES OF REFUGE ........ ............................... 21 6.4.1 On -site Emergencies ............................................................................. .............................21 6.4.2 Off -site Emergencies .............................................................................. .............. ..............._22 6.5 DECONTAMINATION OF PERSONNEL DURING AN EMERGENCY....................................................... ............................... 22 6.6 EMERGENCY SITE SECURITY AND CONTROL .......................... 22 6.7 PROCEDURES FOR EMERGENCY MEDICAL TREATMENT AND FIRST AID ..................................................... .............................. 22' . 6.7.1 Chemical Exposure ............................................................................... :............................22 6.7.2 Personal Injury .....................................................................................: .............................23 6.7.3 Fire or Explosion ..............................:......................:.........................:.... :............................23 6.7.4. Emergency Contact ............................................................................... .............................23 SECTION 7 LEVELS OF PERSONAL PROTECTION REQUIRED FOR SITE ACTIVITIES................................................................... ............................... 25 7.1 DERMAL PROTECTION..... 25 7.2 RESPIRATORY PROTECTION .......................... ............................... 26 7.3 HEALTH AND SAFETY EQUIPMENT ..... ............ .............. ................ 26 SECTION 8 DUST CONTROL .....................................:...............:....... ... ............................. 27 8.1 DUST SUPPRESSION ...................................... : .......... : .......... ................. 27,. SECTION 9 SITE CONTROL MEASURES ......................................... .............:................. 28 9.1 SITE ACCESS ....................................................... ............................... 28 9.2 PERMITS ..................:.............................................. ....:.........:..............28 9.3 WORK ZONES ..................................................... ......:.........:.............. 28 SECTION 11.0 SITE SAFETY INSPECTIONS ............................:....... .......::......:............... 29 APPENDIX A FORMS .......................................................................... ............................... 30 WAYNE PERRY, INC IMMEDIATE NOTIFICATION OF HES INCIDENT TO THE CORPORATION ................ ............................... 31 PROJECT HEALTH AND SAFETY PLAN BRIEFING ACKNOWLEDGMENT ........................................ ............................... 32 DAILY FIELD SAFETY FORM ................................... ............................... 33 TAILGATE SAFETY MEETING FORM 34 ..................... ............................... JOB SAFETY ANALYSIS FIELD SHEET ................... ............................... 35 JOB SAFETY ANALYSIS FIELD SHEET CHECK LIST .......................... 36 FIELD ACTIVITY DAILY LOG ................................... ............................... 37 AIR MONITORING DATASHEET .............................. ............................... 38 APPENDIX B HEAT AND COLD STRESS HAZARDS ..................... ......................:........ 39 Incident Free Operation Page 8 of 68 Site, Safety andtHealthrPlan. = .a ' �... . Table B -1 Heat Stress Symptoms, Treatment and Prevention ......................:.... .............................40 Table B -2 Cold Stress Symptoms, Treatment and Prevention ........................... .............................42 APPENDIX C HEALTH HAZARD QUALITIES OF CHEMICAL HAZARDS ................ 45 Table C -1 Health Hazard Qualities of Chemical Hazards .................................. .............................46 APPENDIX D EVACUATION MAP .................................................... ............................... 54 EVACUATIONMAP ..................................................... ............................... 55 APPENDIX E ADDENDUM ................................................................. ............................... 56 APPENDIXF MSDS ................................. :........................................................... ................ 57 APPENDIX G JOB SAFETY ANALYSES ........................................... ...........................:... 58 APPENDIX H PERMITS ............................... .............................:. ........................... 68 Incident Free Operation Page 9 of 68 $ite Safety anciHealthhPlan ;_ , SECTION 1. PURPOSE AND POLICY 1.1 Introduction This Site Safety and Health Plan (SSHP) establishes personnel protection standards and mandatory . safety practices and procedures for field activities. The SSHP assigns responsibilities, establishes standard operating procedures, and provides for contingencies that may arise during site activities. It is the objective of this plan to establish procedures that will ensure Incident Free Operation (IFO) during field activities. All site personnel shall use this SSHP as the primary source of information on site 'safety and health matters. This SSHP will be kept on site during field activities.. : The Site Safety and Health (SSH) Officer will conduct a..pre- mobilization briefing on the contents of this SSHP for all site personnel involved in the covered activities. All' such personnel must sign the Plan Acceptance Form in Appendix A acknowledging that they have attended the pre - mobilization meeting, and have read and understood this SSHP and will abide by its contents. The SSH Officer or designee will conduct daily "tailgate" site safety and health meetings to discuss work to be performed-that day and the potential hazards thatwill be monitored during the work. The Daily Field Safety Form in Appendix A will be completed and signed by. all personnel after the `.`tailgate" meeting and before commencing the day's activities. The Field Team Leader or the SSH Officer will maintain a copy of the form and transmit it to the Project SSH Officer_ at the end of each day. 1.2 Regulatory Framework This plan and all site activities will be in compliance with the requirements of the California and Federal Hazardous Waste. Operations and Emergency Response Standards (29 Code of Federal Regulations [CFR] 1910.120) and Title 8 California Code of Regulations [CCR] 5192. 1.3 Modifications to the SSHP Although the SSHP focuses on the specific site conditions described here, it must remain flexible because, conditions may change and unforeseen situations may arise that require deviations from the original plan. This flexibility allows modification of the SSHP by the Project or Site Manager, Field Team Leader, and SSH Officer to take into account changing site conditions such as new data on chemical hazards, weather, and modifications to the scope of work. Recognizing that construction activities at the site may be long -term and may consist of many different field tasks, this SSHP has been organized in a manner that will easily identify the current ongoing work being conducted Addendums to the SSHP, as needed, will be clearly displayed in Appendix E. Changes to the SSHP must be approved by the SSH Officer and the Project or Site Manager. If unanticipated field conditions are encountered on site that are not addressed in this SSHP, these conditions Incident Free Operation Page 10 of 68 . Site;$afety, and:Iealth 3Plan " shall be immediately reported to the Field Team Leader, the SSH Officer, and Project SSH Officer. If necessary, any field activities shall be halted until the SSHP has been amended to reflect changed conditions and reviewed and approved by the SSH Officer and Project or Site Manager. 1.4 Stop Work Authority All site personnel are empowered, expected, and have the responsibility to stop_ their own work and the work of co- workers, or other contractors if any person's safety or the environment are at risk. NO repercussions will result from this action. . Site or project conditions that are possible reasons to stop work and to consider modifications to the SSHP include: Site temperatures outside the range predicted in this SSHP (possibly resulting in greater risk of heat or cold stress); Personal protective equipment (PPE) breakthrough or unexpected degradation; Unusual odors that can not be identified; Unexplained, elevated readings on an organic vapor, monitor; and Unexpected changes in soil coloration or texture that might indicate undisclosed contamination. This list is not comprehensive and should be used only as guidance (also refer to Section 6, for emergency response procedures). 1.5 Contractor/ Subcontractor Coordination Certain activities performed may require the use of another contractor and/or subcontractor. All contractors and subcontractors will be provided with a copy of this SSHP, which they must adopt. This plan is applicable to the other contractors /subcontractors insofar as Wayne Perry, Inc. employees will be directing the work of contractors /subcontractors performing this work. . In addition, other contractors /subcontractors will prepare their own SSHP, which must meet or exceed the requirements of this SSHP, for activities specific to their portion of the work or that are not covered by this plan (i.e., monitoring 'well installation). The other contractors' /subcontractors' SSHP will be reviewed by the Project or Site Manager and Project SSH Officer prior to commencement of field activities. Any plan not acceptable to the Project or Site Manager and SSH Officer will be rejected, and contractors /subcontractors will not proceed unless the plan is amended as required. Field supervisors will adopt and comply with the contractors' /subcontractors' SSHP insofar as they will be directing the contractor /subcontractor work. Incident Free Operation Page 11 of 68 Site' Safety:;and' Health Plan SECTION 2 SITE DESCRIPTION AND SCOPE OF WORK 2.1 Site Description Current site is a 7 — Eleven located at 4647 Wilson Rd. Bakersfield, Ca 93309. .1. 2.2 Site Map Please see site map attached ( Figure 1) 2.3 Scope of Work The scope of work consists of the following: • Removal of concrete and canopy • Removal of 3 UST's and piping • Soil sampling • Backfill and compact. • Asphalt back; strip'and.clean up Site, afety ;and `Hea1t11 Plan SECTION 3 PROJECT TEAM ORGANIZATION AND RESPONSIBILITIES WAYNE PERRY, INC. HEALTH & SAFETY ORGANIZATION CHART 3.1 Site Safety and Health Officer The SSH . Officer is responsible for ensuring that activities conducted are performed in conformance with this SSHP and applicable contractor /subcontractor SSHP(s). He /she has the authority to stop work if actions or conditions are judged unsafe or not in conformance with the SSHP(s), including, but not limited to, inadequate or improper use of required PPE. Should unexpected conditions arise during fieldwork that warrant changes to this or other SSHP(s), those changes must be reviewed and approved by him/her. The responsibilities of the SSH Officer will be to: 1. Assure that appropriate personnel protective equipment is available and is properly utilized by all on -site contractor personnel; 2. Assure that personnel are aware of the provisions of this plan and are instructed in the work practices necessary to ensure safety and the procedures for dealing with emergencies; Incident Free Operation Page 13 of 68 3. ' . Assure the completion of the Project Site Safety and . Health Plan Bri efing Acknowledgment Form (see Appendix A) by all personnel prior to their going on site, and ensuring that they understand the provisions of the form; 4. Conduct tailgate SSH meetings as required by this SSHP; 5. Assure that personnel are aware of potential hazards associated with the site; 6. Monitor the safety performance of all personnel to ensure that the required work practices are employed; 7. Immediately stop work and correct any work practice_ s or conditions ' that may result in injury or unsafe conditions; 8.. Conduct safety inspections and complete appropriate forms weekly (see Appendix A); 9. Prepare accident/incident reports (see Appendix A); and 10. Consult with the SSH Officer. He /she will maintain documented proof of the following requirements: 1. Copies of the Project Site Safety and Health Plan Briefing Acknowledgement Form 2. Minutes of tailgate SSH meetings 3. Copies of safety construction inspections 4. Copies of accident/incident reports 5. Records of any decisions or changes made from consultations with the Project SSH Officer 3.2 Field Workers All fieldworkers, including contractors /subcontractors, are responsible for their personal site safety and health and the safety of their co- workers. All field team members are responsible for reading and complying with this and-other project SSHP(s). As required by this SSHP they are responsible for becoming aware of any hazardous site conditions, wearing the appropriate PPE, paying attention at all times, and stopping work and reporting any unsafe working conditions to the SSH Officer or Field Supervisor. No person shall perform an activity that he /she believes may endanger his/her site safety and health or the site safety and health of others. Everyone has the responsibility to stop work in the face of unsafe working conditions or practices. 3.3 Other Contractors and Subcontractors The other contractor /subcontractor site supervisors will report to the Field Supervisor. The other contractor /subcontractor site safety representatives will report to the SSH Officer. All safety representatives and officers will collaborate to ensure this and other applicable SSHPs are followed. Incident Free Operation Page 14 of 68 ,. �. I Site`Safety °agd Heait Plan, ,,4 ; �; � i,i� ,';; SECTION 4 TRAINING AND MEDICAL MONITORING REQUIREMENTS 4.1 General Training All workers at the site will have received a general safety orientation for the site, including, but not limited to, a review of the contents of this Site Safety and Health Plan. If required by site conditions, all workers involved in field operations will have received at least OSHA 24 -hour site .safety and health training that meets the requirements of 29 CFR 1910.120. Fieldworkers and other contractors /subcontractors must have completed an 8 -hour refresher training course during the past 12 months if the 24 -hour training- course was received prior to the past 12 months. No person shall work alone in a field operation. The Field Supervisor and the SSH Officer must have completed a Supervisory. training course in addition to the above training requirements, when required by site conditions. Fieldworkers who may need to wear respirators during site activities will receive instructions, demonstration, and practice on how the respirator should be worn, how to adjust it, and how to determine if the respirator fits properly, as described in the Respiratory Protection Program for their company. Certification of fit - testing will be provided to the Project SSH Officer before respirator usage is implemented.. 4.2 Site - Specific Training The WPI SSH Officer, On -site SSH Officer, and Project Manager will participate in a pre job SSH briefing prior to mobilization. The briefing will cover the contents of this SSHP including roles and responsibilities, job hazard analysis, and safe work practices. The site's emergency response and evacuation practices will be reviewed in detail. The SSH Officer or designee will conduct a daily "tailgate" site safety and health meeting to discuss the work to be performed that day and the potential hazards that will be monitored during the work. The SSH Officer or his/her designee will note the topics covered during the daily "tailgate" training on the Daily Field Safety Form. Incident Free Operation Page 15.of 68 SiteSafety�'andIealtb; °Plane 4.3 Medical Monitoring Employees will participate in medical surveillance as required by 29 CFR 1910.120. Participation will be based on the following: 1. All employees who are or may be exposed to hazardous substances or health hazards at or above the established permissible exposure limit, above the pubiished exposure levels for these substances, without regard to the use of respirators, for 30 days or more a year 2. All employees who wear a respirator for 30 days or more a year or as required by 1910.134 3. All employees who are injured, become ill or develop signs or symptoms due to possible overexposure involving hazardous substances or health .hazards from an emergency response or hazardous waste operation Note:. Wayne Perry, Inc:, employees are not members of HazMat teams. Incident Free Operation Page 16 of 68 'S.afety';and.Hea0h ' � ite� _ Plan. SECTION 5 SITE HAZARD ANALYSIS 5.4 Chemical Hazards The properties and potential health hazards associated with each of the known contaminants are listed in Appendix C. Note that the potential health hazards in the table are those expected from exposure to elevated concentrations, such as 'pure product. Concentrations at the site are expected to be in the parts per billion to parts per million range (with the exception of a few inorganic compounds). Material Safety Data Sheets (MSDSs) applicable to this project are in Appendix F. Unprotected site workers could be exposed to chemicals via inhalation of volatiles„ or dust, dermal contact, and incidental, ingestion of contaminated material. Administrative and engineering controls shall be used to minimize exposures (i.e., wetting soil to reduce dust). Site workers shall wear the personal protective equipment (PPE) prescribed in Section 7 of this SSHP as protection from these potentially harmful exposures. Materials of trade (i.e., reagents, compressed gases, preservatives, decontamination solutions) can be hazardous if stored or handled improperly. MSDSs shall be maintained on site for all of these chemicals. Such materials that might be used include isobutylene for calibrating the PID, and hexane for decontamination when sampling for petroleum hydrocarbons. The MSDSs for hazardous materials of trade will be kept in the MSDS binder located in each field safety kit. If these materials are transferred to another container, the container will be properly. labeled according to the OSHA HAZCOM requirements. The U.S. Department of Transportation (DOT) might define some chemicals brought to the site as hazardous materials. All ' workers who ship the materials or transport them by road must receive training'm shipping dangerous goods.. All hazardous materials that are shipped (i.e., via Federal Express) or are transported by road must be properly identified, labeled, packed, and .documented by trained workers. Contact the Field Supervisor or the SSH Officer for additional information. Incident Free Operation Page 17 of 68 F % I OR- 2"F Situ Safety afth,P-1!a'n,111_ V i it 5.2 Non-Chemical Hazards The three broad categories of non-chemical hazards include safety, physical, and biological hazards. The anticipated hazards and the required controls to reduce or eliminate these hazards include: Table 5-1 Safety Hazards • Slip, trips and falls • Fire • Sharp objects. • Entanglement � Construction and heavy equipment • Poor lighting hazards • Overhead utilities • Flying debris /objects (line-of-fire) • Buried utilities • Electrical or other energized equipment • Suspended loads • Visible lightning • Back strain or injury, • Pinch points (e.g., cuts to hands, crushed fingers or toes) • Vehicle traffic • Soft ground conditions • Dike stability • Working on/near water. Table 5-2 : Physical Hazards • Noise Low light/ darkness • Muscle strain' Table 5-3 Biological Hazards • Insect stings (wasps, bees) • Arthropod bites (spiders, ticks) • Loose or feral animals • Heat stress • Cold stress • Wet conditions • Poisonous plants (i.e., poison oak, ivy; . or sumac) • Mosquitoes • Snakes and other poisonous animals ti Incident Free Operation Page 18 of 68 Site Safety aid Health;P l an- _'I- 5.3. Hazard Analysis and Mitigations by Task Safety, physical, and biological hazards can be mitigated by the use of proper work procedures and controls, safety equipment (i.e., hard hat, safety glasses, steel- toed/shanked shoes, protective gloves), good communication among all on -site personnel, and being alert to potential hazards. Job Safety Analyses are listed Appendix G. Incident Free Operation Page 19 of 68 Site Safetyand Health Plan SECTION 6 EMERGENCY RESPONSE PLAN All site activities present a degree of risk to on -site personnel. During routine operations, risk is - minimized by establishing good work practices, staying alert and using proper personal protective equipment. Unpredictable events such as physical injury, chemical exposure, or fire may occur and must be anticipated. First aid kits and•portable fire extinguishers will be kept on site during all fieldwork. 6.1. Guidelines for Pre - Emergency Planning and Training Workers must read this SSHP and familiarize themselves with the information in this chapter. Before any field work, the field workers should review the SSHP and its emergency response procedures. Workers shall have a copy of the emergency contacts and phone numbers immediately accessible on site and know the route to the nearest emergency medical services (see the front of this SSHP). In addition, task - specific overviews and any addendums /revisions tathis SSHP.will be kept current in the front of this document. In addition, all workers must be familiar with site safe work practices and evacuation procedures included in the site specific training (Section 4.2). Furthermore, any and all incidents such as near misses /losses, injuries, accidents, and related investigations must be reported immediately to the. site safety and health officer. 6.2 Emergency Recognition and Prevention Emergency conditions are considered to exist 'if- Any member of the field crew is involved in an accident or experiences any adverse effects or symptoms of exposure while on site. A condition is discovered that suggests the existence of a situation more hazardous than anticipated. Some ways of preventing emergency situations are listed below. Workers should remain close together to assist each other during emergencies. During operations, on -site workers act as safety backup to each other. Off -site personnel provide emergency assistance. All field workers should make use of their senses to alert themselves to potentially dangerous situations that they should avoid, e.g., presence of strong'and irritating or nauseating odors, odors different from those normally encountered at the site. Workers should practice unfamiliar operations before doing the actual procedure, in the field. Field workers shall be familiar with the physical characteristics of investigations, including: Incident Free Operation Page 20 of 68 Site Safety and;HeaIth, -PTan' „ ex7 — Wirfd direction in relation to contamination zones — .Accessibility to co- workers,,equipment, and vehicles — Communications — Areas of known or suspected contamination — Site access and egress — Nearest water sources. Workers and equipment in the work area enclosure should be minimized, consistent with effective site operations. Work areas for various operational activities must be established. In, the event that any member of a field work team experiences any adverse effects or symptoms of exposure while on the scene, or organic vapors and combustible vapors exceed the action limits, the entire field team will immediately halt work and act according to the instructions provided by the Site Safety Officer. The discovery of any condition that would suggest the existence of a situation more hazardous than anticipated will result in the evacuation of the field team and reevaluation of the hazard, and the level of protection required. 6.3 Personnel Roles, Lines of Authority, and Communication Procedures, during an Emergency All personnel should know their responsibilities during an emergency; know who is in - charge during an emergency, and the extent of their authority. This section outlines worker roles, lines of authority, and communication procedures during emergencies. In the event of at! emergency at the site,' the Site Safety Officer will assume control and will be responsible for on -site decision - making. This individual has the authority to resolve all disputes about health and safety requirements and precautions. He /she will also be responsible for coordinating all activities until the ambulance, rescue, fire personnel, etc. arrives on site. The Site Safety Officer will- ensure that other contractors /subcontractors Safety Officer(s), the Health & Safety Officer, the Wayne Perry Project Manager or Site Manager are contacted as soon as possible after the emergency occurs. The Site Safety Officer and other on -site personnel will have an established line of communication for emergency calls and reports (e.g., radio, cell phone, etc.). 6.4 Evacuation Routes and Procedures, Safe Distances, and Places of Refuge 6.4.1 On -site Emergencies Incident Free Operation Page 21 of 68 Site Safe and•Health Plan In the event of an on -site emergency, employees will evacuate the area as instructed by the SSH Officer, transport injured personnel, or take other measures to mitigate the situation. The site - specific evacuation location will be the on -site place of refuge during an emergency. Should conditions warrant or as directed by the SSH Officer, site personnel should use the shelter -in- place facility as a secondary place of refuge. Fieldworkers will identify evacuation routes to the evacuation locations before initiating work. Please see Evacuation Route Map (Figure 2) in. Appendix D. 6.4.2 Off -site Emergencies In the event of an off -site emergency, remain on site until instructions to relocate are given. If wind conditions or the nature of the emergency make the site - specific location building unsafe as a place of refuge, the SSH Officer will make the decision to relocate. Off -site emergencies at the site location are indicated by verbal notification. If verbally notified, work will stop immediately, equipment will be de- energized and/or secured as necessary for safety reasons and personnel will go immediately to the site staging area. Personnel will follow the I directions of the SSH Officer, who will determine the nature of the emergency and appropriate steps to take. 6.5 Decontamination of Personnel during an Emergency Uninjured employees that are required to evacuate, a contaminated area in an emergency situation should follow the decontamination procedures described in Section 10 of this SSHP, if possible. If the emergency precludes following the procedures in Section 10 (Le. the emergency presents an immediate threat to employee health and safety); then at a minimum, personnel should move into a safe area and remove protective equipment. Care should be taken to minimize contamination of the safe area and personnel. Contaminated clothing should be placed in plastic, garbage bags or other suitable containers for. later drumming and disposal. Employees should wash or shower as, soon as possible. If a member .of the field team is injured or exposed to chemicals, the emergency procedures outlined in Section 6.7 below should be followed. 6.6 Emergency Site Security and Control For this project, the Site Safety Officer and/or the Project Safety Officer will maintain a list of personnel who are on site and who are in the work area. This list will be compiled on the Daily Field Safety Form (Appendix A) that will be completed during the dally. "tailgate" meetings. The names and cell phone numbers of the field crew will also be written on Page V of this SSHP. In an emergency situation, all personnel will be evacuated except rescue and response personnel who are needed to attend to the injured. 6.7 Procedures for Emergency Medical Treatment and First Aid 6.7.1 Chemical Exposure Incident Free Operation Page 22 of 68 Site Safety and,Health:Plan R` In the event of chemical exposure (skin contact, inhalation, ingestion) the following procedures should be implemented: Another team member (buddy) should remove the individual from the immediate area of contamination. Precautions should be taken to avoid exposure of other individuals to the chemical. If the chemical is on the individual's clothing, the clothing should be removed if it is safe to do SO. If the chemical has contacted the skin, the skin should be washed with copious amounts of water, preferably under a shower. In case of eye contact, an emergency eyewash should be used. For site work activities with a high splash potential, a portable eyewash station will be located at the site. Eyes should be washed for at least 15 minutes. If necessary, the victim should be transported to the nearest hospital or medical center (refer to Hospital Location-Map on page 4 of this SSHP). The Site Safety Officer should be notified as soon as possible. If necessary, an ambulance should be called to transport the victim. 6.7.2 Personal Injury In the event of personal injury: Field team members trained in first aid can administer treatment to an injured worker. If the injury is more serious than a first -aid case, the victim should be transported to the nearest hospital or medical center. If necessary, an ambulance should be called to transport the victim:, They Site Safety Officer is responsible for completing an Incident Report Form, appropriate BBS forms (Appendix A) and submitting them to the Project H &S Officer and the Site Manager. 6.7.3 Fire or Explosion In the event of a fire or explosion, personnel will evacuate the area immediately and administer necessary first aid to injured employees. First aid kits will be kept on site during field work as a part of the field H &S kit, along with a fire extinguisher, which is available for small fires. Personnel will proceed to a safe area, contact the Site Safety Officer (see emergency contact numbers at the front of this SSHP), and phone 911. Upon contacting 911, state your name, nature of the hazard (fire, high combustible vapor levels), the location of the incident, and whether there were any physical injuries requiring an ambulance. Do not hang up until 911 has indicated that they have all of the information they require. 6.7.4 Emergency Contact Emergency phone numbers.and a map to the hospital are found at the front of this SSHP. Incident Free Operation Page 23 of 68 Site Safety; and�Health °Plan. -1, Site Safety.and Health Plan.. $ kF SECTION 7 LEVELS OF PERSONAL PROTECTION REQUIRED FOR SITE ACTIVITIES - Personal protective equipment (PPE) that will be required on site during the field activities is described. in this section. Additional PPE may be required depending on other permit requirements (excavation, safe entry) requirements (see Section 9) and/or field conditions.. 7.1 Dermal Protection Minimum. dermal protection for all field team members will be Level D, which includes.standard ' work clothes that include sleeved shirts, long pants, approved safety glasses with side shields or "wrap around"' protection, hardhat, and sturdy shoes or steel - toed/shanked leather work boots. For specific tasks, Level D dermal protection shall be upgraded as follows: All personnel, who perform sampling or monitoring activities shall wear inner surgical-style. nitrile and outer chemical- resistant nitrile gloves. For groundwater sampling only, outer gloves may be removed to assure adequate dexterity when handling sampling containers. 'If surgical- . style nitrile gloves become wet they should be dried immediately. Surgical -style gloves should be changed frequently to assure their integrity. Steel toed/shanked neoprene or rubber boots or overboots shall be worn.when in wet/muddy areas. Uncoated TyveO suits shall be worn over standard works clothes as described above whenever contact is likely with contaminated soils, poisonous plants, or stickers. Water impermeable (e.g., Saranex°) coveralls shall be worn when sampling surface water, and whenever contact.is likely with wet contaminated soils,'groundwater, sediments or surface water. Safety vests must.be worn when working around heavy equipment or vehicles. Hearing protection will be worn when working around construction, heavy, or other equipment or tools or, whenever conversations cannot be held at distances of 3 feet or less without shouting. Personal Flotation Device if on or near water. Full body harness and lifeline with "shore- watch" personnel if working around soft sediments or water per Section 2.3. Certain activities, such as hand excavation of contaminated soils, may require Level C dermal protection. Dermal protection for Level C includes the following items to supplement Level D protection: impermeable suit (e.g. coated Tyveko or Saranex ° suit), impermeable boots (e.g. coated TyveO or Saranexe booties), and nitrile gloves. Particular tasks to be performed in Level C dermal protection can be upgraded as described above for Level D. Incident Free Operation Page 25 of 68 Site Safe , and Health Plan, 7.2 Respiratory Protection Level D - No respiratory protection. Level C - Full -face piece air purifying respirator (APR) equipped with a cartridge (NIOSH approved) to be determined based on the hazards present, as appropriate. Level B - is not expected to be needed for these operations. 7.3 Health and Safety Equipment The on -site field team will have the health, and safety equipment noted below readily available during site activities. Copy of the SSHP(s) Radio or cell phone First -aid kit Fire extinguisher (type A -B -C) Paper towels and hand soap Traffic safety vests (for work around heavy equipment) Work gloves (when handling equipment) Nitrile gloves Safety Cones and/or Barricade tape and/or barricades Liquids to drink PPE as appropriate to Task as described in Sections 7.1 and 7.2 t Incident Free Operation Page 26 of 68 Srte':Safety�and, Health SECTION 8 DUST CONTROL 8.1 Dust Suppression Water will be used as the primary method of Dust Suppression on the site. Incident Free Operation Page 27 of 68 Site Safe alth Plan SECTION 9 SITE CONTROL MEASURES 9.1 Site Access No visitors shall be allowed on -site without prior approval of the Site. Safety Officer, or designee. 9.2 Permits Prior to starting any field activities, appropriate approvals and permits should be obtained. Any field activities, independently of its size, will require a WPI General Work Permit. Additional permits may. be required depending the, site; operating facilities may have several permit procedures. Some of these, include, but are not limited to, a soil excavation permit, hot work permit, confined space entry permit, and other state ,or local permits. 9.3 Work Zones Prior to starting any field activities, an area in which work will be conducted will be classified as the works zone. The work zone will be properly protected, barricaded, or cordoned off in order to maintain a clear and distinct separation from work activity and non -work activity areas. Incident Free Operation Page 28 of 68 SECTION 11.0 SITE SAFETY INSPECTIONS The following inspections /reports will be conducted / prepared: �It' Location By a Frequency. Safety Field Report Appendix A SSH Officer Daily Incident Free Operation Page 29 of 68 Site Safety and, Health Plan " , ,. s: SECTION 11.0 SITE SAFETY INSPECTIONS The following inspections /reports will be conducted / prepared: �It' Location By a Frequency. Safety Field Report Appendix A SSH Officer Daily Incident Free Operation Page 29 of 68 i Site'Safety and Hea`Ith.Plan -`s- APPENDIX A FORMS Incident Free Operation Page 30 of 68 Site Safetyarid I3ealth`Plan` Wayne Perry, Inc Immediate Notification of HES Incident to the Corporation Use this form when making notifications to Corporate Emergency Response Staff: Call (800) 883 -0352 or (714) 826 -0352 BUSINESS UNIT: LOCATION: . PERSON MAKING NOTIFICATION: LOCAL DATE AND TIME OF NOTIFICATION: CONTACT NUMBER: TYPE OF INCIDENT: ❑ FATALITY ❑ SPILL/RELEASE ❑ INJURIES ❑ NATIONAL /SIGNIFICANT LOCAL NEWS COVERAGE ❑ OTHER SIGNIFICANT HES INCIDENT LOCAL DATE AND TIME OF INCIDENT-' DESCRIPTION OF INCIDENT: INJURIES: ACTIONS TAKEN OR PLANNED: ASSISTANCE REQUIRED: MEDIA ATTENTION: OTHER INFORMATION: CORPORATE TEAM MEMBER TAKING REPORT: Incident Free Operation Page 31 of 68 Daily Field Safety Form This form must be completed by the Site Safety Officer, and turned in at the end of each day for review. Failure to turn in completed form at the end of the day will result in suspension of further field activities. 1) Field Supervisor: Date: Project Name: 2), Check Pages 29 and 30 of this SSHP. for a checklist of required equipment and supplies. Special topics for daily safety meeting, near misses, problems from previous day, changes in work plan, etc. 3) Daily Safety Meeting Sign -Off Sheet Name Company C Incident Free Operation Page 33 of 68 g: *� Site` Safety and Health Daily Field Safety Form This form must be completed by the Site Safety Officer, and turned in at the end of each day for review. Failure to turn in completed form at the end of the day will result in suspension of further field activities. 1) Field Supervisor: Date: Project Name: 2), Check Pages 29 and 30 of this SSHP. for a checklist of required equipment and supplies. Special topics for daily safety meeting, near misses, problems from previous day, changes in work plan, etc. 3) Daily Safety Meeting Sign -Off Sheet Name Company C Incident Free Operation Page 33 of 68 a a u , Site *,Safety and Healtti Plan`' Tailgate Safety Meeting Form Project NamelNumber: Date: Time: Client: Work Activities: Hospital Name/Address:' , Hospital Phone No.: Ambulance. Phone No.: Safety Topics Presented. Chemical Hazards: Physical Hazards Personal Protective Equipment: Activity: PPE Level: Activity: PPE Level: Activity: PPE Level: Activity: PPE Level: Activity: PPE Level: New Equipment: Other Safety Topic(s): Attendees Name Printed Signature Meeting conducted by. Incident Free Operation Page 34 of 68 Site`Safety arid°He althj:Plan , .,t _ Job Safety Analysis Field Sheet Date: Job No. Permit No. Work Type: ❑ New ❑ Revised Work Site (Project Location): Organization: Perannnl Prntective F,nninment (PPF.1_ Level Hard Hat ❑ Yes ❑ No Safety Access/Location Steel -toed Boots ❑ Yes ❑ No Safe Haven: Hearing Pro tection —s ecific to task ❑ Yes ❑ No Wind Direction: High Visibility Traffic Safety Vest ❑ Yes ❑ No Evacuation Route: Protective Gloves— Leather work gloves ❑ Yes ❑ No Safety Glasses & Screen Face Shield' ❑ Yes ❑ No Assembly Point: Other: Job Steps (What are you doing?) Potential Hazard(s) Critical Action(s) EXAMPLE: Backfilling Slips, Trips, Falls Clear walkways of equipment, vegetation, excavated material, tools, and debris. Mark, identify or barricade other obstructions.. 'Audit the Job Audit Time: Supervisor's Comments and Initials: Audit the Job Audit Time: Supervisor's Comments and Initials: Audit the Job Audit Time: Supervisor's Comments and Initials: Audit the Job Audit Time: Supervisor's Comments and Initials: JSA Form originated by: Incident Free Operation Page 35 of 68 Job Safety Analysis Field Sheet Check List Date: Job No. Permit No. Work Type: ❑ New ❑ Revised Work Site (Project Location): organization: Site' Health a >t ❑ Combustibles ❑ Safety and Plan >r. ❑ Spark Containment ❑ - ❑ Entry Permit Job Safety Analysis Field Sheet Check List Date: Job No. Permit No. Work Type: ❑ New ❑ Revised Work Site (Project Location): organization: C nnsider the fnllnwinv- check the items that annly to the inh_ and then review with the work crew- Permits Welding Hazards (Environmental) ❑ Required ❑ Flashbums ❑ Electrical Shock ❑ Cold Work ❑ Combustibles ❑ Heat Stress ❑ Hot Work ❑ Spark Containment ❑ Heavy Objects ❑ Entry Permit ❑ Shields ❑ Hot/Cold Surf. or Mat. ❑ All Conditions Met ❑ Grounding ❑ Inadequate Lighting ❑ Signed Off When Complete ❑ Water Hose ❑ Line Breaking ❑ Other: ❑ Fire Extinguisher ❑ Noise Personal Protective Equip. PE ❑ Fire Blanket ❑ Poor Access/Egress ❑ Types of Gloves ❑ Fire Watch ❑ Sharp Objects ❑ Composition of Gloves: ❑ Sewer Covers ❑ Other: ❑ Other: Hazards /Chemicals ❑ Special Purpose Gloves Overhead Work ❑ Chemical Burn Shin/Eyes ❑ Tyvek Suit ❑ Barricades ❑ Flammable ❑ Acid Suit/Slicker Suit ❑ Signs ❑ Ingestion ❑ Rubber Boots ❑ Hole Cover ❑ Inhalation ❑ Mono Goggles vented/non- ❑ . Handrail ❑ Skin contamination ❑ Face Shield ❑ Other: Hazards/Body ❑ Respirator Electrical ❑ Fall Potential ❑ Fresh Air ❑ Locked & Tagged Out ❑ Pinch Points ❑ Ear Protection ❑ Try Start/Stop Switch ❑ Slip-Trip Potential ❑ Safety Harness" ❑ GFCI Test ❑ Other: ❑ Burning Goggles ❑ Assured Grounding Other Work in Area ❑ Other: ❑ Extension Cord Inspection ❑ Others Working Overhead Tools ❑ Other: ❑ Type Work Others Doing ❑ Current Inspection Lifting ❑ PPE Due to Other Work ❑ Proper Tools for the Job ❑ Forklift ❑ Other: ❑ Good Tool Condition ❑ Cherry Picker Access ❑ Qualifications ❑ Load Chart ❑ Scaffold (Properly Inspected) ❑ Other: ❑ Angle ❑ Ladder Tied Off) Emergency Equipment ❑ Crane ❑ Manlift ❑ Fire Extinguishers ❑ Proper Rigging Practices ❑ Personnel Basket (Inspected & Approved) ❑ Safety Shower ❑ Manual Lifting ❑ Evacuation Route ❑ Condition of Equipment ❑ Operator Trainin ❑ Other:. ❑ Operation Certificate ❑ Special Provisions ❑ Other: ('nniin.A Cnnra !Know 4hP fnllnwino•1 ' Possible hazards within the confined First signs of exposure. How to summons help. space. How to track personnel. Entering and exiting the confined space. Maintain contact with all entrants by voice or visual. Do not attempt to rescue unless you are Remain at entry point; assume no duties a part of a coordinated effort. will take you from there. JSA Form originated by: Supervisor/Foreman: Recommendations: Incident Free Operation Page 36 of 68 Site Safetyand Healtli Plan Date , No. Sheet of Field Activity Daily Log Project Name Project No. Field Activity Subject: Description of Daily Activities and Events: Visitors on Site: Changes from Plans and Specifications, and Other Special Orders and Important Decisions: . Weather Conditions: Important Telephone Calls: Personnel on Site: Signature: Date:. Incident Free Operation Page 37 of 68 Site Safety and Health -Plan Air Monitoring Datasheet Job No.: Date: Monitoring by: Activity/Locations Instrument Make: Model: Serial No.: Calibration Time: Personnel Monitored: Concentration (ppm) Breathing Sample Respirator Time Zone Source Other Location Comments Use (Y/N) Submit copy of this form to the project file. Submit copy to the Project Health and Safety Office if respiratory protection was required and/or concentrations exceeded respiratory protection criteria in this SSHP. Incident Free Operation Page 38 of 68 VA APPENDIX B HEAT AND COLD STRESS HAZARDS Incident Free Operation Page 39 of 68 � � an VA APPENDIX B HEAT AND COLD STRESS HAZARDS Incident Free Operation Page 39 of 68 Site�S � i ��afyd 1IaWill ' a Table B -1 Heat Stress Symptoms, Treatment and Prevention Heatstroke and Heat Hyperpyrexia Symptoms Heatstroke: (1) hot dry skin; red, mottled, or cyanotic; (2) high and rising core temperature, 40.5 °C or over; (3) brain disorders; mental confusion, loss of consciousness, convulsions, or coma, as core temperature continues to rise. Fatal if treatment delayed. Heat Hyperpyrexia: milder form; core temperature lower; less severe brain disorders; some sweating... Treatment Heatstroke: immediate and rapid cooling by immersion in chilled water with massage, or by wrapping in wet sheet with vigorous fanning with cool dry air. Avoid overcooling. Treat shock if present. Heat hyperpyrexia: less drastic cooling required if sweating still present and core temperature <40.5 °C. Prevention Medical screening of workers. Selection based on health and physical fitness. Acclimatization for 8 to 14 days by graded work and heat exposure. Monitoring�.workers during sustained work in severe heat. -:Heat Syncope Symptoms Fainting while, standing erect and immobile in heat. Treatment Remove to cooler area. Recovery prompt and complete. Prevention Acclimatization. Intermittent activity to assist venous return to heart. Heat Exhaustion Symptoms (1) Fatigue, nausea; headache, giddiness; (2) skin clammy and moist; .. _ complexion pale, muddy, or with hectic flush; (3) may faint on standing, with rapid thready pulse and low blood pressure; (4) oral temperature normal or low but rectal temperature usually elevated (37.5 to 38.5 °C). Water- restriction type: urine volume small, highly concentrated. Salt - restriction type: urine less concentrated, chlorides less than 3 g/liter. Treatment Remove to cooler environment. Administer salted fluids by mouth or give intravenous infusions of normal saline (0.9 percent) if patient is unconscious or vomiting. Keep at rest until urine volume and salt content indicate that salt and water balances have been restored. Prevention Acclimatize workers using a breaking -in schedule for 1 or 2 weeks. Supplement dietary salt only during acclimatization. Ample drinking water to be available at all times and to be taken frequently during workday. Heat Cramps Symptoms Painful spasms of muscles used during work (arms, legs, or abdominal). Onset during or after work hours. Treatment Salted liquids by mouth, or more prompt relief by intravenous infusion. Incident Free Operation Page 40 of 68 Site Safet y "'- and HealthPlan.�: a •� -��,�� ��. ���G �,�,� f.° «r, Prevention Adeauate salt intake with meals. In unacclimatized men, provide salted (0.1 Heat Rash Symptoms Profuse tiny raised red vesicles (blister like) on affected areas. Pricking sensations during heat exposure. Treatment Mild drying lotions. Skin cleanliness to prevent infection. Prevention Cooled sleeping quarters to allow skin to dry between heat exposures. Heat Fatigue — Transient Symptoms Impaired performance of skilled sensorimotor, mental, or vigilance tasks, in heat. Treatment Not indicated unless accompanied by other heat illness Prevention' Acclimatized and training for work in the heat. Incident Free Operation Page 41 of 68 Site Safety and Health'Plan Table B -2 Cold Stress Symptoms, Treatment and Prevention Have the person drink warm, sweet drinks (sugar water or sports -type drinks) if they are alert. Avoid drinks with caffeine (coffee, tea, or hot chocolate) or alcohol. Have the person move their arms and legs to create muscle heat. If they are unable to do so, place warm bottles or hot packs in the arm pits, groin, neck; and head areas DO NOT rub the person's body or.place them in a warm water bath — this may stop the heart. Prevention Dress appropriately. Layer clothing to adjust to changing environmental temperatures. Wear a hat and gloves, in addition to underwear that will keep water away from the skin (i.e., polypropylene). Take frequent breaks in warm, dry shelters. Change wet clothes as soon as possible. Perform work during the warmest part of the day. Avoid exhaustion or fatigue because energy is needed to keep muscles warm. Incident Free Operation Page 42 of 68 Frostbite Symptoms Pale, waxy - white, hard, numb skin and tissue. Treatment Move person to warm, dry area. Remove wet or tight clothing that may cut off blood flow to the affected area. DO NOT rub the affected area. Gently place the affected area in a warm (105 °F) water bath and monitor the water temperature to slowly warm the tissue. Warming takes about 25 -40 minutes. After the affected area has been warmed, it may become puffy and blister, and have a burning feeling or numbness. When normal feeling, movement, and skin color has returned, the affected area should be dried and wrapped to keep it warm If there is a chance that the affected area may get cold again, do not warm the skin; this can cause severe tissue damage. Seek medical attention as soon as possible. Prevention Dress appropriately. Layer clothing to adjust to changing environmental temperatures. Wear a hat and gloves, in addition to underwear that will keep water-away from the skin (i.e., polypropylene). Take frequent breaks in warm, dry shelters. Change wet clothes as.soon aspossible. Perform work during the warmest part of the day. Avoid exhaustion or fatigue because energy is needed to keep muscles warm-. Impending Hypothermia Symptoms Skin may become pale, numb, and waxy. Muscles become tense. Fatigue and weakness begins to show. Body's core temperature drops to or below 95 °F. Treatment Move the person to a warm, dry area. DO NOT leave the person alone'. Remove any wet clothing and replace with warm, dry clothing or wrap the person in blankets. Have the person drink warm, sweet drinks (sugar water or sports -type drinks) if they are alert. Avoid drinks with caffeine (coffee, tea, or hot chocolate) or alcohol. Have the person move their arms and legs to create muscle heat. If they are unable to do so, place warm bottles or hot packs in the arm pits, groin, neck; and head areas DO NOT rub the person's body or.place them in a warm water bath — this may stop the heart. Prevention Dress appropriately. Layer clothing to adjust to changing environmental temperatures. Wear a hat and gloves, in addition to underwear that will keep water away from the skin (i.e., polypropylene). Take frequent breaks in warm, dry shelters. Change wet clothes as soon as possible. Perform work during the warmest part of the day. Avoid exhaustion or fatigue because energy is needed to keep muscles warm. Incident Free Operation Page 42 of 68 Site Safety ;a'nd Health >P14 n. Mild Hypothermia Symptoms Uncontrolled shivering begins. The individual is still alert, but movement becomes less coordinated and some pain and discomfort exists. The body's core temperature drops to 93.2 °F. Treatment Call for emergency help (ambulance or 911). Move the person to a warm, dry area. DO NOT leave the person alone. Remove any wet clothing and replace with warm, dry clothing or wrap the person in blankets. Have the person drink warm, sweet drinks (sugar water or sports -type drinks) if they are alert. Avoid drinks with caffeine (coffee, tea, or hot chocolate) or alcohol. Have the person move their arms and legs to create muscle heat. If they are unable to do so, place warm bottles or hot packs in the arm pits, groin, neck, and head areas DO NOT rub the person's body or place them in a warm water bath, this may stop the heart. Prevention Dress appropriately. Layer clothing to.adjust to changing environmental temperatures. Wear a hat and gloves, in addition to underwear that will keep water away from the skin (i.e., polypropylene). Take frequent breaks m warm, dry shelters. Change wet clothes as soon as possible. Perform work during the warmest part of the day. Avoid exhaustion or fatigue because energy is needed' to keep muscles warm. ; Severe Hypothermia Symptoms The skin becomes cold and may appear bluish in color. The individual is weak and uncoordinated. Speech is slurred, and the victim appears exhausted, denies problem, and may resist help. Gradually, there is a loss of consciousness, with little or no breathing occurring. The individual may be rigid and appear dead. Body's core temperature drops below 87.8 °F. Treatment Call for emergency help (ambulance or 911). Check for pulse and breathing. If neither is present, begin CPR and mouth - to -mouth resuscitation. Continue until medical help arrives. Never give up on a victim. Move the person to a warm, dry area. DO NOT leave the person alone. Remove any wet clothing and replace with warm, dry clothing or wrap the person in blankets. Have the person drink warm, sweet drinks (sugar water or sports -type drinks) if they are alert. Avoid drinks with caffeine (coffee, tea, or hot chocolate) or alcohol. Have the person move their arms and legs to create muscle heat. If they are unable to do so, place warm bottles or hot packs in the arm pits, groin, neck, and head areas DO NOT rub the person's body or place them in a warm water bath — this may stop the heart. Incident Free Operation Page 43 of 68 NSite 9' e- afe - y,and Health °Plan .o s Prevention Dress appropriately. Layer clothing to adjust to changing environmental temperatures. Wear a hat and gloves, in addition to underwear that will keep water away from the skin (i.e., polypropylene): flake frequent breaks. in warm, dry shelters. Change wet clothes as soon as possible. Perform work during the warmest part of the day. Avoid exhaustion or fatigue because energy is needed to keep muscles warm. Incident Free Operation' Page 44 of 68 l i3 as.,p. .rid . t ti k , �,���''I; SiteySaFfety aid�HealttiPlan����� Mn APPENDIX C HEALTH HAZARD QUALITIES OF CHEMICAL HAZARDS Incident Free Operation . Page 45 of 68 Site "Safety and�sHealtli,:Plam � " b Table C -1 Health Hazard Qualities of Chemical Hazards Arsenic 0.01 mg/m' - 0.01 5 NA, NA Silver -gray or tin- white, brittle, odorless Odor Ionization Compound PEL TLV b' IDLH a Thresho Potential e' Physical Description/Health (ppm) (ppm) (ppm) ld d' (eV) Effects /Symptoms . respiratory irritation, skin spots, and lung (ppm) and lymphatic cancer. Mutagen; Acetone 1,000 1,000 2,500 NA 9.69 Colorless liquid with a fragrant, mint -like 0.5 mg/m3 50 NA (2,400 mg/m3). (2,400 [10% mg/m3 odor. Irritation eyes, nose, throat; headache, compounds as Ba) '. mg/m3) LEL] dizziness, central nervous system respiratory tract. Causes skin bums,, depression; dermatitis. Aldrin 0.25 mg/m3 0.25 0.25 0.017 NA White crystalline solid with a mild chemical arrhythmia. mg/m3 mg/m3 0.5 500 4.7 odor. Binds to soil and can become airborne [29 CFR [skin] with an aromatic odor. Eye, nose, skin, and with soil disturbance. Irritation eyes, nose, respiratory system irritant. Causes [8 CCR 52181 throat; headache, dizziness, nausea and gait, fatigue, anorexia, exhaustion, vomiting, loss of coordination; coma, dermatitis, bone marrow depression, and respiratory depression. Ammonia 50 25 300 NA 10.18 Colorless gas with a pungent, suffocating 0.002 4 NA (35 mg/m3) (18 mg/m3) Mg/M3 mg/m3 odor. Irritation eyes, nose, throat; dyspnea membranes. Causes berylliosis, anorexia, (breathing difficulty), wheezing, chest pain; low- weight, weakness, chest pain, pulmonary edema; pink frothy sputum; skin burns, vesiculation; liquid: frostbite. Antimony 0.5. mg/m3 0.5 mg/m3 50 Noncombustible solid in bulk form, but a mg/m3 moderate explosion hazard in the form of dust when exposed to flame. Causes irritation eyes, skin, nose, throat, mouth; cough; dizziness; headache; nausea, vomiting, diarrhea; stomach cramps; insomnia; anorexia; unable to smell Arsenic 0.01 mg/m' - 0.01 5 NA, NA Silver -gray or tin- white, brittle, odorless (Inorganic, as As) [29CFR Mg/Ml. mg/m3-. solid. Causes ulceration of the nasal 1910.1018]' `' septum, dermatitis, gastrointestinal [8 CCR 5214] E disturbances, nervous system degeneration, respiratory irritation, skin spots, and lung and lymphatic cancer. Mutagen; experimental teratogen, and carcinogen. Barium 0.5 mg/m3 0.5 mg/m3 50 NA NA White, odorless solid, although appearance (soluble mg/m3 and properties vary with specific compounds as Ba) '. compounds. Irritates eyes, skin, and upper respiratory tract. Causes skin bums,, gastroenteritis, muscle spasms, potassium decrease, slow pulse, and momentary arrhythmia. Benzene 1 0.5 500 4.7 9.24 Colorless to light- yellow liquid (solid <42°F) [29 CFR [skin] with an aromatic odor. Eye, nose, skin, and 1910.10281 `' respiratory system irritant. Causes [8 CCR 52181 giddiness, headaches, nausea, staggered gait, fatigue, anorexia, exhaustion, dermatitis, bone marrow depression, and leukemia. Mutagen, experimental teratogen, and carcinogen. Beryllium 0.002 mg/m3 0.002 4 NA NA Hard, brittle, gray- white, metallic solid. Mg/M3 mg/m3 Irritates lungs, skin, eyes, and mucous membranes. Causes berylliosis, anorexia, low- weight, weakness, chest pain, coughing, blue skin, clubbed fingers, Incident Free Operation Page 46 of 68' Site Safety and Health F1an y4 Cadmium (dust) . 0.005 mg/m3 °' 0.01 9 NA NA Silver- white, blue- tinged, lustrous, odorless, Odor Ionization Compound PEL 0 TLV b' IDLH cl Thresho Potential 0 Physical Description/Health (ppm)' (ppm) (ppm) : Id d' (eV) Effects /Symptoms" lung cancer. Also attacks kidneys. (ppm) Mutagen, experimental teratogen, and Chlordane 0.5 mg/m3 0.5 mg/m3 NA NA NA Amber, viscous liquid with a mild, pungent pulmonary insufficiency, dermatitis, and weakness, vision problems, vomiting, lung cancer. Mutagen and carcinogen. Biphenyl 0.2 0.2 100 NA 7.95 Colorless to pale - yellow solid with a 0 mg/m3) (1 mg/m) mg/m3 pleasant; characteristic odor. Irritation eyes, taken by mouth can cause convulsions -and throat; headache, nausea, lassitude Chromium (metal) 1 mg/m 0.5 mg/m' 250 NA, NA Blue -white to steel gray, lustrous, brittle, mg/m3 (weakness, exhaustion), numb limbs; liver Cadmium (dust) . 0.005 mg/m3 °' 0.01 9 NA NA Silver- white, blue- tinged, lustrous, odorless, [29CFR mg/m3'/ Mg/M3_ metallic'solid. Causes pulmonary. edema,' 1910.1027] " 0.002 shortness of breath, coughing, chest [8 CCR 1532 & mg/m3 w tightness /pain, loss of sense of smell, chills, 5207] muscle aches, headaches, nausea, vomiting, diarrhea, mild anemia, and prostatic and lung cancer. Also attacks kidneys. Mutagen, experimental teratogen, and Carbon Disulfide 20 1 500 NA 10.08 Colorless to faint - yellow liquid with a sweet (30) [ceiling] (3 mg/m) ether -like odor. Dizziness, headache, poor (100) [30 -min [skin] sleep, lassitude (weakness, exhaustion), max peak] anxiety, anorexia, weight loss; psychosis; polyneuropathy; Parkinson -like syndrome; ocular changes; coronary heart disease; gastritis; kidney, liver injury; eye, skin burns;_ dermatitis; reproductive effects. Chlordane 0.5 mg/m3 0.5 mg/m3 NA NA NA Amber, viscous liquid with a mild, pungent odor. Headaches, irritability, confusion, weakness, vision problems, vomiting, stomach cramps, diarrhea, and jaundice have.occurred in people who breathed air containing high concentrations of chlordane or accidentally swallowed small amounts of chlordane. Large amounts of chlordane taken by mouth can cause convulsions -and death. Chromium (metal) 1 mg/m 0.5 mg/m' 250 NA, NA Blue -white to steel gray, lustrous, brittle, mg/m3 hard, odorless, metallic solid. Irritates eyes, skin, and respiratory system. Causes lung fibrosis. Chromium (II) and 0.5 mg/m' 0.5 mg/m' 250 NA . NA Properties. vary with compound'. Irritates (III) Compounds mg/m3(I eyes and causes sensitization dermatitis. .(as Cr) _ I) 25 mg/m3 Chromium (VI) 0.5 mg/m' 0.05 15 NA NA Cr03 occurs as dark red, odorless flakes or (water soluble mg/m3 mg/m3 powder, often used in solution as H2CrO4, compounds) wb;,.b may burst a sealed container due to CO2 release. Properties vary with compound. Causes eye, respiratory, and skin irritation. Causes nasal septum perforation, eye injury, conjunctivitis, skin ulcers, sensitization dermatitis, blood cell 'disorders, liver and kidney damage, and Incident Free Operation Page 47 of 68 Site Safetyand °Health.'lan 77 Odor Ionization Compound PEL 0 TLV "l IDLH " Thresho Potential ej Physical Description/Health (ppm) (ppm) (ppm) Id ai (eV). Effects /Symptoms Incident Free Operation Page 48 of 68 lung cancer. Mutagen and carcinogen. Cobalt metal 0.1 mg/m3 0.02 20 > 1 NA Odorless, silver -gray to black, magnetic, (dust and fumes as mg/m3. mg/m3 mg/m3 / somewhat malleable, hard, solid metal. Co) Causes coughing, shortness of breath, wheezing, decreased pulmonary function, dermatitis, low- weight, fibrosis, asthma, and respiratory hypersensitivity. Fumes cause metal fume fever. Suspected carcinogen: Copper 1 mg/m3 1 mg/m3 100 NA NA Reddish, lustrous, malleable, and odorless, (dust and mists as mg/m3 solid metal. Irritates eyes, nose, skin, and Cu) pharynx. Causes a metallic taste, nasal perforation, nausea, vomiting, and dermatitis. In animals, causes anemia and lung, liver, and kidney damage. Experimental teratogen. DDT 1 mg/m3 1- rng/m3 500 NA NA White, crystalline solid with no odor or Mg/M3 taste. Nervous system effects including excitability, tremors, and seizures. Dieldrin 0.25 Mg/M3 0.25 0.5 0.041 NA White crystalline solid with a mild,chemical mg/m3 mg/m3 odor. Binds to soil and can become airborne with soil disturbance. Irritation eyes, nose, throat; headache, dizziness, nausea and vomiting, loss of coordination, coma, respiratory depression. Endrin 0.1 mg/m3 0.1 mg/m3 NA 0.018 " . NA White or colorless solid. Central nervous system effects including headaches, dizziness, nervousness, confusion, nausea, .vomiting, and convulsions. Ethylbenzene 100 100 800 NA 8.76 Colorless liquid with an aromatic odor. (435 mg/m3) (435 [10% Irritation eyes, skin, mucous membrane; Mg/M3) LEL] headache; dermatitis; narcosis, coma. bis -(2- 5 mWM3 5 mg/m 5,000 NA NA Colorless, oily liquid with a slight odor: Ethylhexyl)phthala mg/m3 Eyes, respiratory system, central nervous to system, liver, reproductive system, gastrointestinal tract. Fluorene 0.1 0.1 25 NA 15.70 Nonflammable gas, but an extremely strong (0.2 mg/m3) (0.2 oxidizer. Irritation eyes, nose, respiratory Mg/M) system; laryngeal spasm, wheezing; pulmonary edema; eye, skin burns; in animals: liver, kidney damage. Gasoline NA NA NA NA NA Clear liquid with a characteristic odor. Irritation eyes, skin, mucous membrane; dermatitis; headache, lassitude (weakness, exhaustion), blurred vision, dizziness, slurred speech, confusion, convulsions; chemical pneumonitis (aspiration liquid); possible liver, kidney damage; [potential occupational carcinogen]. Heptachlor 0.5 mg/m3 0.5 mg/m3 NA 0.3 NA White powder with camphor (mothball) Mg/M3 odor. Central nervous system effects including dizziness, confusion, or Incident Free Operation Page 48 of 68 Site Safety and. Health' Plan Odor Ionization Compound PEL d TLV bl IDLH' Thresho Potential '� Physical Description/Health (ppm) (ppm) (ppm) Id d' (eV) Effects /Symptoms` Incident Free Operation Page 49 of 68 convulsions. Hydrogen Sulfide 20 10 100 0.00001- 10.46 Colorless gas with strong odor of rotten (50) [10 -min max (15 mg/m) 0.8 w eggs. Rapidly fatigues sense of smell. peak] [10 -min] Irritates eyes and, respiratory tract. Causes ' interrupted breathing, coma, convulsions, conjunctivitis, eye pain, tearing, visual intolerance to light, corneal vesicles, dizziness, headaches, fatigue, irritability, insomnia, and gastrointestinal disturbances. Isophorone 25 4 2,000 NA 9.07 Colorless to white liquid with a peppermint- -.(140 mg/m3) (23 mg/m3) like odor. Irritation eyes, nose, throat; headache, nausea, dizziness, lassitude (weakness, exhaustion), malaise (vague feeling of discomfort), narcosis; dermatitis; in animals: kidney, liver damage. Isopropyl benzene 50 50 900 NA 8.75 Colorless liquid with a sharp, penetrating, (245 mg/m) (245 [10% aromatic odor. Irritation eyes, skin, mucous •mg/m3) LEL] membrane; dermatitis; headache, narcosis, coma. 2- Methyl phenol 5 2.3 250 NA 8.93 White crystals with a sweet, tarry odor (a .(22 mg/m3) (10 mg/m3) liquid above 88 °F).. Irritation eyes, skin, [skin] mucous membrane; central nervous system effects: confusion, depression, respiratory failure; dyspnea (breathing difficulty), irregular rapid respiration, weak pulse;, eye, skin burns; dermatitis; lung, liver, kidney, pancreas damage. 4- Methyl phenol 5 2.3 250 NA 8.97 Crystalline solid with a sweet, tarry odor (a (22 mg/m3) (10 mg/m3) liquid' above 95T).Jrritation eyes, skin, [skin] mucous membrane; central nervous system effects: confusion, depression, respiratory failure; dyspnea (breathing difficulty), irregular rapid respiration, weak pulse;; eye, skin burns; dermatitis; lung, liver, kidney, pancreas damage. Lead 0:05 mg/m3 0.05 100 NA NA Heavy, ductile, bluish -gray, soft metal. [29 CFR mg/m3 mg/m3 Irritates eyes. Causes weakness, 1910.1025] `' . exhaustion, insomnia, facial pallor, [8 CCR 5198] 9' anorexia, low- weight, malnutrition, constipation, abdominal pain, gastritis, colic, constipation, gingival lead line, anemia, wrist and ankle paralysis, joint pains, tremors, low blood pressure, and kidney disease. Mutagen, experimental teratogen, and suspected carcinogen. Mercury 0.01 mg/m3 0.01 2 NA NA Appearance and odor vary depending on the (alkyl as Hg) 0.04 mg/m3 mg/m3 mg/m3 specific compound. Silver- white, heavy, [ceiling] [skin] odorless, liquid or tin -white ductile, (alky) 0.01 mg/m3 0.05 10 NA' NA malleable, soft, solid metal. Causes skin [ceiling] mg/m3 mg/m3 tingling, incoordination, joint dysfunction, [skin] visual and hearing disturbances, spasticity, Incident Free Operation Page 49 of 68 Site =Saf6t and Health -,Plan: Incident Free Operation Page 50 of 68. Odor Ionization Compound PEL 'TLV bl IDLH cl Thresho (ppm) (PPM). (ppm) Id dl Potential Physical Description/Health (eV) Effects /Symptomsu (ppm) . (elemental and 0.025 mg/m3 0.025 10 NA NA jerking limbs, dizziness, salivation, tearing, inorganic) [vapor] mg/m3 mg/m3 nausea, vomiting, diarrhea, constipation, [skin] [inorg] skin burns, emotional disturbances, kidney [skin] injury, and possible teratogenic effects. Methane NA NA NA NA NA Colorless; odorless, tasteless gas. Simple asphyxiant, which diminishes the amount of oxygen in the air that is breathed. Causes . rapid respiration, air hunger, diminished mental alertness, impaired muscular coordination, faulty judgment, depressed sensations, emotional instability, fatigue, nausea, vomiting, collapse, unconsciousness, convulsions, deep coma, . and death: Dangerous fire and explosion hazard when exposed to hear or flame. Methylene 25 50 160 -620 Colorless liquid with mild, sweet odor. chloride Irritation skin. If you breathe in large amounts of methylene chloride you may feel unsteady, dizzy, and have nausea and a tingling or numbness of your forger and , toes. A person breathing smaller amounts of methylene chloride may become less. attentive and less accurate in tasks requiring hand -eye coordination. Molybdenum 5 mg/m3 5 mg/m3 1,000 NA NA Appearance and odor vary with specific (soluble mg1m3 compound. In animals, irritates eyes, nose, compounds as Mo) and throat, and causes anorexia, incoordination, shortness of breath, anemia, and kidney disorders. Mutagen and experimental teratogen. - Naphthalene 10 10 250 NA 8.12. Colorless to brown solid with an odor of (50 mg/m3) (50 mg/m) - mothballs. Irritation eyes; headache, confusion, excitement, malaise (vague feeling of discomfort); nausea, vomiting, abdominal pain; irritation bladder; profuse sweating; jaundice; hematuria (blood in the urine), renal shutdown; dermatitis, optical neuritis, corneal damage. Incident Free Operation Page 50 of 68. Site Safety andI3ealth. Plan "' "� ,rvk . ` �`: � � • Odor Ionization Compound PEL a' TLV bl IDLH 'j Thresho Potential 'j Physical Description/Health (ppm) (ppm) (ppm) ld d' (eV) Effects /Symptoms Nickel metal and . 1 mg/m 3 0.015 10 NA NA Metal: Lustrous, silvery, odorless solid. other compounds mg/m3 mg/m3 Sensitization dermatitis, allergic asthma, (as Ni) pneumonitis; [potential occupational Octane 500 75 1,000 NA 9.82 Colorless liquid with a gasoline -like odor. (2350 mg/m) (350 [10% Irritation eyes; nose; drowsiness; dermatitis; mg/m3) LEL] chemical pneumonitis (aspiration liquid); in (385) animals: narcosis. [ceiling] (1,800 mg/m) [ceiling . 15 -min] Selenium 0.2 mg/m" 0.2 mg/m 1 0.0002 NA Amorphous or crystalline, red to gray solid. Mg/M3 mg/m3 Irritates eyes, skin, nose, and throat. Causes visual disturbances, pallor, nervousness, depression, headaches, chills, fever, ' shortness of breath, bronchitis, metallic taste, garlic breath, gastrointestinal disturbances, dermatitis, brittle hair and nails, and eye and skin burns. In animals, causes cirrhosis and localized death of liver tissue, and kidney and spleen damage. Experimental teratogen and questionable carcinogen. Silver 0.01.mg/m3 0.01 10 NA NA Metal: White, lustrous solid. Blue -gray (metal dust and mg/m3 mg/m3 eyes, nasal septum, throat, skin; irritation, soluble ulceration skin; gastrointestinal disturbance. compounds, as Ag) - Thallium 0.1 mg/m3 0.1 mg/m3 15 NA NA Appearance and odor vary depending upon (soluble [skin] [skin] mg/m3 the specific soluble thallium compound. compounds; as TI) Nausea, diarrhea, abdominal pain, vomiting; ptosis, strabismus; peri neuritis;'tremor; retrosternal (occurring behind the sternum) tightness, chest pain, pulmonary edema; convulsions, chorea, psychosis; liver, kidney damage; alopecia; paresthesia legs. Toluene 200 100 500 NA 8.82 Colorless liquid with sweet, pungent, (300) (375 . benzene -like odor. Irritates eyes and nose. [ceiling] mg/m) Causes fatigue, weakness, dizziness, (500) headaches, hallucinations or distorted [10 -min max perceptions, confusion, euphoria, dilated peak] pupils, nervousness, tearing, muscle fatigue, insomnia, skin tingling, dermatitis, bone marrow changes, and liver and kidney damage. Mutagen and experimental teratogen. Toxaphene 0.5 mg/m3 0.5 mg/m3 200 0.14 NA Amber, waxy solid with turpentine odor. Mg/M3 High doses can cause lung, nervous system, and kidney damage. Trichloroethylene ' 100 50 NA 100 NA Colorless liquid with mild, sweet odor and Incident Free Operation Page 51 of 69 Site Safety an'dIt lth Plan =f Compound PEL " TLV b' (ppm) (ppm) Odor Ionization IDLH `� Thresho Potential Physical Description/Health (ppm) ld d/ (eV) Eftects /Symptoms (ppm) NA NA sweet, burning taste. Breathing small Trimethylbenzene amounts may cause headaches, lung irritation, dizziness, poor coordination, and difficulty concentrating. Breathing large amounts may cause impaired heart function, unconsciousness, and death. Breathing it for long periods may cause nerve, kidney, and liver damage: Drinking large amounts may cause nausea, liver damage, unconsciousness, impaired heart function, or death. Drinking small amounts for long periods may cause liver and kidney damage,,' impaired immune system function, and impaired fetal development in pregnant Vanadium (dust) 0.5 mg.Vz05 /m3 Women, although the extent of some of 35 ° these effects is not yet clear. [ceiling] Skin contact for short periods may cause mg/m3 skin rashes. 1,2,4 -- NA 25 NA NA 8.27 Clear, colorless liquid with a distinctive, Trimethylbenzene (125 aromatic odor. Irritation eyes, skin, nose, mg/m3) throat, respiratory system; bronchitis; hypochromic anemia; headache, drowsiness, fatigue, dizziness, nausea, incoordination; vomiting, confusion; chemical pneumonitis . NA 25 NA NA 8.39 Clear, colorless liquid with a distinctive, Trimethylbenzene (125 aromatic odor. Irritation eyes, skin, nose, Mg/M3) throat, respiratory system; bronchitis; hypochromic anemia; headache, drowsiness, lassitude (weakness, exhaustion), dizziness, nausea, incoordination; vomiting, confusion; chemical pneumonitis (aspiration liquid). Vanadium (dust) 0.5 mg.Vz05 /m3 0.05 mg 35 ° Yellow -orange powder or dark -gray, [ceiling] V /m3 [15- mg/m3 odorless flakes dispersed in air. Irritation [resp] min] eyes, skin, throat; green tongue, metallic taste, eczema; cough; fine rales, wheezing, bronchitis, dyspnea (breathing difficulty). Xylene (o -, m -, 100 100 900 0.05 -200 8.56 Colorless liquid with aromatic odor.. P- and p- isomers) (435 mg/m3) (435 f 8.44 (p) isomer is a solid <567. Irritates eyes, skin, Mg/M3) nose, and throat. Causes dizziness, drowsiness, staggered gait, incoordination, irritability, excitement, corneal irregularities, conjunctivitis, dermatitis, anorexia, nausea, vomiting, abdominal pain, and olfactory and pulmonary changes. Also targets blood, liver, and kidneys. Mutagen and experimental teratogen. Zinc (zinc oxide) 5 mg/m3 m/ 5 mg/m3 nv 500 NA NA Fine, white or yellowish, odorless (10 mg/m) (15 MY/m) mg/m3 particulate. Irritates respiratory system. Causes metallic taste, cough, chills, fever, Incident Free Operation Page 52 of 68 Site Safety and .Hea'Ith1 Plan ' { 5 ° y Odor Ionization Compound PEL TLV bl IDLH d Thresho Potential a Physical Description/Health (ppm) (ppm) (ppm) Id's (eV) Effects /Symptoms [ceiling] tight chest, headaches, rales, blurred vision, muscle aches, nausea, vomiting, dry throat, weakness, lower back pain, exhaustion, fatigue, vague discomfort, shortness of breath, and decreased pulmonary function. Fumes cause metal fume fever. Mutagen and experimental teratogen. a/ PEL = Permissible Exposure Limit. OSHA- enforced average air concentration to which a worker may be exposed for an 8 -hour workday without harm. Expressed as parts per million (ppm) unless noted otherwise. -b/ _TLV = Threshold Limit Value - Time - Weighted Average. Average air concentration (same definition as PEL, above) recommended by the American Conference of Governmental Industrial Hygienists (ACGIH), 2001 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices. c/ IDLH = Immediately Dangerous to Life or Health. Air concentration at which an unprotected worker can escape without debilitating injury or health. effects. Expressed as ppm unless noted otherwise. IDLH values are published in the NIOSH Pocket Guide to Chemical Hazards, June 1997. d/ When a range is given, use the highest concentration. e/ Ionization Potential, measured in electron volts (eV), used to determine if field air monitoring equipment_can. detect substance. Values are published in the NIOSH Pocket Guide to Chemical Hazards, June 1997. f/ Olfactory fatigue has been reported for the compound and odor may not serve as an adequate warning property. g/ Refer to expanded rules for this compound in Title 8 of the California Code of Regulations h/ Respirable fraction. i/ Total dust. j/ (ceiling) = Ceiling concentration which should not be exceeded at any time. k/ Based on exposure limits for petroleum distillates (petroleum naphtha). I/ Irritation threshold. m/ Based on fume. n/ NIOSH recommends reducing exposure to the lowest feasible concentration, and limiting the number of workers exposed. o/ Based on selenium oxide. p/ Indicates that the IDLH value was based on 10% of the lower explosive limit for safety considerations, even. though relevant toxicological data indicated that irreversible health effects or impairment of escape existed only at higher concentrations ( NIOSH Pocket Guide to Chemical Hazards, June 1997). q/ Based on dust. r/ Refer to expanded rules for this compound in the Code of Federal Regulations. s/ Total dust containing no asbestos and less than 1% crystalline silica. t/ Descriptions and toxic properties reflect chemicals in their concentrated or pure form.' Chemical concentrations at the site are mostly expected to be in the parts per billion or parts per million range. u/ Based on coal tar pitch volatiles Incident Free Operation Page 53 of 68 T Siic Safety sand Health Plan: Incident Free Operation Page 54 of 68 Site Saifety.and Ilea lh`Plan; ° J Evacuation Map Incident Free Operation Page 55 of 68 Site Safety and Health Plan = ` = APPENDIX E ADDENDUM Incident Free Operation Page 56 of 68 Site safety and Health Plan APPENDIX F MSDS Incident Free Operation Page 57 of 68 i APPENDIX G JOB SAFETY ANALYSES Incident Free Operation Page 58 of 68 SfSa nHd ealt .h1Pan Job Safety Analysis— (Concrete Breaking and Removal) Field staff must review job - specific work plan and coordinate with project manager to verify that all up -front logistics are completed prior to staging work including, but not limited to, permitting, success agreements and notification to required contacts (e.g., site managers, inspectors, clients, subcontractors, etc.). Additionally, a tailgate safety meeting must be performed and documented at the beginning of each work day: Safe Performance Self Assessment (SPSA) procedures must be used during field activities. Also consider weather conditions (heat, cold, rain, and lightning). Date: ®Yes Work Type: Concrete Breaking and Removal Work Site: Steel -toed Boots Organization: Wayne Perry, Inc. Personal Protective Equipment PPE , Level D Hard Hat ®Yes 1 ❑ No Steel -toed Boots ® Yes ❑ No Hearing Protection —s ecific to task ® Yes ❑ No High Visibility Traffic Safety Vest ® Yes ❑ No Protective Gloves— Leather work gloves ® Yes ❑ No; Safety Glasses & Screen Face Shield ® Yes ❑ No Other: the task safely... 2 .. Steps Potential Concrete Replacement 1 Perform Safe, Vehicle /pedestrian traffic, slips, trips Perform an SPSA to ensure that Performance Self and falls on uneven and wet surfaces, there is adequate work space to Assessment (SPSA) or other construction equipment on safely perform the task that inspection upon site. Lack of complete awareness and individuals are trained to perform arrival focus of potential hazards. the task and that work site personnel-have all the necessary tools and equipment to complete the task safely... 2 Site Check -in Potential vehicle and pedestrian Wear Safety Vest when walking hazards. Conflict with deliveries or -through facility. Choose a walk, other site /station operations. path away from the flow of traffic.. Make eye contacfwith vehicle traffic to ensure that they see work site personnel prior to walking through lot. Notify Station Manager or other personnel upon arrival and, if required,: sign visitor's log. 3 Inspect, assess and Bodily injuries, toes, eyes, extremities Review all PPE ensuring it is in put on PPE and /or death. Hand injury from broken good working condition. Put on concrete and rebar. Foot injury from required operable PPE: hard hat heavy concrete. Hearing damage is required at all times, fully and /or loss from engine /machinery enclosed goggles must be worn noise. Respiratory injury/illness from when working around loose dust inhalation. Dehydration from concrete cutting machinery, wear excessive heat. Sunburn from working leather gloves when handling in direct sun. concrete chunks and rebar, hearing protection (ear muffs) must be worn if working around loud, noisy machinery, ie saw Incident Free Operation Page 59 of 68 . Site Safety`and Health Plan Incident Free Operation Page 60 of 68 .. Steps Potential Hazard(s) Critical Action(s) cutting blade or jackhammer (toe caps), wear long pants and steel toed leather shoes, ensure enough drinking water is available in effort to prevent dehydration. If needed, use sun block to protect from sunburn. 4 Survey work area Work at incorrect site or location, use Read construction permits and of inappropriate equipment, site construction drawings, verify rupture /break underground subsurface work/service order. structures, vehicle and pedestrian traffic, work performed in wrong area. 5 Secure /barricade Vehicle and pedestrian customer Barricade by using delineators to work area with traffic in the work area. Potential back caution customers that work is fencing and caution strain and muscle pull from being done and it is not safe to tape lifting /setting barricades. Pinch points enter the work zone. In some to hands when setting up barricades. cases fencing may be required to Tripping while handling barricade insure proper safety. Use proper equipment and /or other equipment on lifting and bending techniques and around site, personal injury. when picking up barricading Inaccurate distance of barricaded area equipment from storage area. could result in injuries to passersby. Insure proper distance.in the securing of work area. 6 Complete Self- Lack of complete awareness and Self- permit should be posted and Permit form focus of potential hazards. Explosion easily made available for due to LEL limits where work is inspection. erformed. 7 Inspect hand /power Faulty or dirty tools may cause injury Make sure hand tools are clean tools, Heavy to the user. Personal injury caused by and free of oil or debris. Insure Equipment using incorrect tool for job. Personal power tools are clean and all (Concrete Breaking, injury due to the poor condition of parts are secure including shields etc.) before starting heavy and concrete breaking and deflectors. - — - -work- equipment. Back strain, eye-, hand, Technicians /workers have proper foot, injuries due to improper use of training and a combination of sledge hammer. certification and experience is using specific task oriented tool /equipment. Insure heavy and concrete breaking equipment is in proper working order. 8 Start Cutting / Flying sparks or debris, dust, and Verify adequate barricading is in Breaking Concrete noise. Damage to property, place. Also verify if site requires pedestrians, customers, and workers to be closed or it is permissible to from concrete breaking equipment. commence while site is open. Re- Explosion due to high LEL limits verify all required PPE is being and /or fire(s). utilized immediately prior to the commencement of cutting concrete. Take LEL readings, use fire blankets and insure flammable spills are addressed before starting to break/cut concrete. Zero LEL required. Plan fors arks. 9 If Backhoe or Jack Personal injury, crushed body parts, Establish communication with Hammer is used in hearing damage or loss, damage to heavy equipment o erator, wear Incident Free Operation Page 60 of 68 Ste Safety and Health Plan a JSA Form originated by: Incident Free Operation Page 61 of 68 .. Steps the cutting of Potential Hazard(s) property Critical Action(s) hearing protection (ear muffs), concrete foot guards, safety vest, hard hat, leather gloves, long pants, safety glasses /goggles. Insure back up alarms are working. Insure common hand signals are understood and used. Insure persons in area are aware of heavy equipment use and are out of the radius of swinging /moving arts. 10 General House Slipping, tripping or falling on objects Constant house keeping, keep Keeping from the cutting activity. Injury to feet, site clean and free of debris. NOV eyes, hands by cutting, dropping, — Insure all protocols are followed lifting and placing concrete debris, in jurisdiction to avoid NOV. back strain. NOV due to escaped Testing, notification, witness water used in cutting concrete. testing, etc... Removing Electrocution due to use of water in hazardous materials, labeling, concrete removal. storing, pick up of, reporting of to work check in with store. Plan work and use of water. Capture waste water (slurry) if required. Plan for water flow and capture in a controlled fashion. Do not let the water run near electrical connections. 11 Remove Broken Back strain, cut hands, crushed feet, Re -check PPE: gloves, safety Concrete from work dust inhalation. shoes, goggles, etc.. Use good area body position to load broken concrete. Use proper lift and bend techniques. Use SPSA before lifting heavy loads; if too heavy use necessary equipment to move heavy load(s). 12. , Inspect and Put. Muscle strain, damaged equipment, Inspect equipment for damage, Away Equipment personal injury to next person that wear and other items that might uses equipment/tools.' pose potential hazards for the next approximate time the equipment may be used in the . future. 13 Perform Safe Vehicle traffic. Personal injury due to Proper site turnover /handoff Performance Self unplanned simultaneous and /or secure area. _Do not allow Assessment (SPSA) operations /projects. next work step in area to begin — For Project until area is first secure. Continuity JSA Form originated by: Incident Free Operation Page 61 of 68 Site" Safetyarid`Health Job Safety Analysis— (Concrete Pad Construction and Pouring) Field staff must review job- specific work plan and coordinate with project manager to verify that all up -front logistics are completed prior to staging work including, but not limited to, permitting, success agreements and notification to required contacts (e.g., site managers, inspectors, clients, subcontractors, etc.). Additionally, a tailgate safety meeting must be performed and documented at the beginning of each work day. Safe Performance Self Assessment (SPSA) procedures must be used during field activities. Also consider weather conditions (heat, cold, rain, and lightning). Date: ® Work Type: ❑ Work Site: Steel -toed Boots Organization: Wayne Perry, Inc. Personal Protective Equipment (PPE), Level (D) Hard Hat ® Yes ❑ No Steel -toed Boots ® Yes ❑ No Hearing Protection—specific to task ® Yes. ❑ No High Visibility Traffic Safety Vest ® Yes ❑ No Protective Gloves— Leather work gloves ® Yes ❑ No Safety Glasses & Screen Face Shield ® Yes ❑ No Other: numbers are listed in the RECON .. Steps Potential Hazard(s) Critical Action(s) Concrete.Pad Construction and Pouring 1 Know the Project 1. Fires 2. Bodily. Injuries 1. The emergency numbers for Emergency (Emergencies) .3. Bodily Injuries (Non- local authorities is located in the Procedures & Emergencies) RECON office trailer next to each Nearest Emergency exit. Dial 911 for fire, medical, and Facility Locations. police emergencies. Also, there are specific local phone numbers that can be dialed. These numbers are listed in the RECON office trailer. 2. The nearest hospital is located on Jimmy Johnson Blvd. The route to the " hospital is posted in the RECON office trailer along with portable maps. Have a first aid kit on site and ensure that all the employees are knowledgeable of its location. Note that everyone on the project has the authority to stop work if an unsafe condition exists or if unsure about a work activity without reprisal from management. 3. We will be using the Tower Medical Walk -In Clinic located at 2100 Hwy. 365 Nederland, Texas, for all non - emergency injuries. Phone number /directions for clinic is posted in the RECON office trailer. 2 Know the Ten 1. Alwa s operate within design - Incident Free Operation Page 62 of 68 Site Safetyand'Health'Plaa` _ 9TV .. Incident Free Operation Page 63 of 68 .. Steps Potential Tenets of or environmental limits. 2. Always Operational operate in a safe and controlled Excellence. condition. 3. Always ensure safety devices are in place and functioning. 4. Always follow safe work practices'and procedures. 5. Always meet or exceed customer's requirements. 6. Always maintain integrity of dedicated systems. 7. Always comply with all applicable rules and regulations. 8. Always address abnormal conditions. 9. Always follow written procedures for high -risk or unusual situations. 10. Always involve the right people in decisions that affect procedures and equipment. 3 Ensure the 1. Slips, Trips, Falls 2. Equipment In Perform an SPSA,before employee is wearing Area 3.Losses /Near Losses beginning any work activity to the proper PPE and eliminate hazards in the work he performs an area. 1. Make sure the cell phone SPSA. is off. Make sure the proper PPE is being worn. 2. Stay alert to the surroundings. Stay alert to ruts, clods, wire, and other obstacles that may be in your path of travel. 3. Make sure to report all losses are near losses to foreman or Recon Site Safety Officer. 4 Pillow Dam 1. Dam Breaking 1. No employee shall enter the trench of Vernor Slough without a - - - - - -- employee being at the pillow dam at all times to watch the water level behind the dam. 2. If the water reaches halfway of the pillow dam the employee will then order everyone out of the trench. 3. The employee will also inspect the 12 inch overflow safety pipe daily to make sure it is not stopped up before anyone enters the trench. 5 Forming Up 1. Slips, Trips Falls 2. Pinch Points 3. 1. Stay alert to ruts, clods, wire, Back Strain 4. Cuts and other obstacles that may be in your path of travel. 2.Avoid pinch points when using hammer. 3. Do not lift anything over 50 pounds get help. 4.100% Glove policy when doing any type of work loves must be on. 6 Placing Wire 1. Slips, Trips Falls 2. Pinch Points 3. 1. Stay alert to ruts, clods, wire, Back Strain 4. Cuts and other obstacles that may be in your path of travel. 2. Avoid Incident Free Operation Page 63 of 68 5A' Form originated b Job Steps t P• Hazard(s) „ Critical Action(s) pinch points when using plies: 3. Do not lift anything over 50 pounds get -help. 4. 100% Glove policy when doing any type of work gloves must be on. 7 Concrete Placement 1. Concrete placement 2. 1. Observe concrete truck Slip/Trip /Falls 3. Skin irritation position and chute during pour operations. Have spotter direct truck while backing or positioning. 2. Assure proper footing when walking in concrete and on reinforcement wire. 3.Avoid prolonged contact:with concrete.,:'.., Wear steel toe, steel shank, rubber boots while walking in concrete. 8., _ Site Cleanup/ 1..PPE 2. Body Position, Slips / . 1. Wear all required PPE. 2. =; Housekeeping trips /falls; Lifting heavy equipment 3. Watch:for trip /slip hazards. Get Procedures help lifting heavy objects like . . ` generators. 3. Watch for blowing debris.,,Throw scrap into dum sters 5A' Form originated b Site Safety and Health Plan Job Safety Analysis— (Backfill & Compaction) Field staff must review job- specific work plan and coordinate with project manager to verify that all up -front logistics are completed prior to staging work including, but not limited to, permitting, success agreements and notification to required contacts (e.g., site managers, inspectors, clients, subcontractors, etc.). Additionally, a tailgate safety meeting must be performed and documented at the beginning of each work day. Safe Performance Self Assessment (SPSA) procedures must be used during field activities. Also consider weather conditions (heat, cold, rain, and lightning). Date: - ® Work Type: Backfill and Compaction Work Site: Steel -toed Boots Organization: Wayne Perry, Inc. Personal Protective Equipment (PPE), Level (D) Hard Hat ® Yes ❑ No Steel -toed Boots ® Yes ❑ No Hearing Protection—specific to task ® Yes ❑ No High Visibility Traffic Safety Vest ® Yes ❑ No Protective Gloves— Leather work gloves ® Yes ❑ No Safety Glasses & Screen Face Shield. ® Yes ❑ No Other: . inspect excavation edges -for- -- - .. Steps Potential UST Installation 1 Backfilling and Compaction of Soil Trips, falls, cave -ins No person shall enter an excavation greater than 5 feet deep unless the excavation has been properly shored or sloped on all sides. Keep 5 feet from edge of excavation, be aware of surface cracks, and visually inspect excavation edges -for- -- - undermining. Shoring and sloping procedures shall be consistent with WPI . Standard Operating Policy •. regarding shoring and sloping. Clear walkways, work areas of equipment, vegetation, excavated material, tools, and debris. Mark, identify, or barricade other obstructions. Stockpile soil at least 3 feet from edge of excavation. Ensure that good housekeeping practices are being performed and maintained. 2 Backfilling and Struck By /Against Heavy Equipment - Wear high - visibility traffic vest. Compaction of Soil personal injury Isolate equipment swing areas. Make eye contact with operators before approaching equipment. Understand and review hand Incident Free Operation Page 65 of 68 Site Safety;.aiia Health Plan - t n t JSA Form originated by: Incident Free Operation Page 66 of 68. .. Steps Potential signals. Stop heavy equipment durin soil compaction testing. .3 Backfilling and Equipment shall approach Compaction of Soil Equipment falling into excavation excavation limits at a controlled speed and perpendicular to an edge (not parallel) that has a stable sidewall.- 4 Backfilling and Ensure backfill material is free of Compaction of Soil Injury and /or property damage from large rocks /debris before placing unloading /compaction of imported into trench. Install backfill material material in lifts no larger than 8 ". 'Use water to achieve adequate saturation level during compaction. 5 JSA Form originated by: Incident Free Operation Page 66 of 68. Site Safety. and Health, lan Job Safety Analysis— (Fence Slat Removal /Installation) Field staff must review job - specific work plan and coordinate with project manager to verify that all up -front logistics are completed prior to staging work including, but not limited to, permitting, success agreements and notification to required contacts (e.g., site managers, inspectors, clients, subcontractors, etc.). Additionally, a tailgate safety meeting must be performed and documented at the beginning of each work day. Safe Performance Self Assessment (SPSA) procedures must be used during field activities. Also consider weather conditions (heat, cold, rain, and lightning). Date: ® Work Type: Remove and Install new PVC slats in fence and gates Work Site: Steel -toed Boots Organization-' Wayne Perry, Inc. Personal Protective Eauinment (PPE). Level (Dl Hard Hat ® Yes ❑ No Steel -toed Boots ® Yes ❑ No Hearing Protection—specific to task ® Yes' ❑ No High Visibility Traffic Safety Vest ® Yes ❑ No Protective Gloves— Leather work gloves ® Yes ❑ No Safety Glasses or Screen Face Shield ® Yes ❑ No Other: Long Sleeve Shirt from fencing.- Use hearing protection, Bard hats;- .. Steps Potential Fence Installation 1 Pre - Construction Personnel not aware of potential All personnel involved with the Meeting & Review of hazards. project will attend a pre -con HASP meeting, including a detailed Personnel are not informed of scope review of the HASP. of work. 2 Remove /Install Slips, trips and falls. Improper lifting Keep equipment/material stored fencing slats techniques. Pinches, cuts, abrasions neatly to mitigate trip hazards. from fencing.- Use hearing protection, Bard hats;- leather work gloves, and steel toed boots. Take breaks as needed. Be sure to ensure level and sturdy round surface. JSA Form originated by: Incident Free Operation Page 67 of 68 y S,iteSafety �and�Health.Plan:�;:. °° APPENDIX H . PERMITS Incident Free Operation Page 68 of 68 BAKERSFIELD CITY FIRE DEPARTMENT -- INSPECTION RECORD Post this Card at the Job Site and DO NOT Remove for Duration of Work Inspection Request Phone No. (661) 326 -3979 UST NEW INSTALL DESCRIPTION DATE SIGNATURE BACKFILL PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT SENSORS AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF TANK TESTING • DESCRIPTION .. I OCCUPANCY TYPE: pl� NOW. F19 CONTRACTOR: p/ PHONE #-71,6 - jC1-S7-Q, REMARKS: AST NEW INSTALL DESCRIPTION DATE SIGNATURE MODIFICATIONS MINOR / MAJOR AST REMOVAL DESCRIPTION DATE SIGNATURE INSTALL; COMPLETE AND ACCEPTED-B RE_DEP-ARTM BUILDING ADDRESS: % W W , JOB DESCRIPTION: 1jvj4jCkjA,,e I OCCUPANCY TYPE: OWNER: - ?/// PERMIT NO. /- Q 4-" CONTRACTOR: p/ PHONE #-71,6 - jC1-S7-Q, I& FD 1743