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PAI GEN 1. i# R11 4. 5. 6. 7. 8. EH 0 ND SAFETY PLAN PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards ❑ Carcinogens: ❑ Corrosives: ❑ Dusts: ❑ Explosives: ❑ Flammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / mea restrictions: 2. Personal Protective Equipment VD Level of Protection: ❑ A ❑ B ❑ C 51 Hard Hat. E3:Bafety Glasses/goggles. gSteel toed/shank shoes or boots. ❑ Flame retardant coveralls. ❑ Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: Safety vest. Two-way communication. PART IV - PLAN APPROVAL �y Plan Prepared b . te: Plan Approved by: "' Date: !/ I 0 SITE HEALTH A ;T I ERAL Sl rE INFORMATION Site Nam Address: Contact P Phone No: Sweeps N ber: Date of investigation/inspection- Proposed Descriptim and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank C losure in Place. ❑ Tank(Pipe Repair. ❑ T ipe Removal. ❑ Rc-excavation. ❑ Installs l7aCC}- Specific S tion of Borings / Monitoring Wells. v to Infonmurfion: Tank No.: Tank Capacity: Tank Con t: Tank Age: Other: Type of rr�� /� eration: f24 -II —I l L=i <5.6 . Release H, story: Evidence of leaks / and contamination: ❑ YES ❑ NO Documen Groundwater contamination: []YES ❑ NO Backgrout d and description of any previous investigation or incidence: Potential I lealth and Safety Physical C oncems: (check all that apply & describe) ❑ Hear o Cold Stress: °F (high ambient temp.) ❑ Noise Sources: i Deficiency: ❑ Oxygo ❑ Excavation: (falls, trips, slipping, cave-ins): 'Mandli ig and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving equip t): specify ❑ Other, Anticipated Biological Hazards: ❑ Stakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other nknown (specify): Narrmive i provide all information which could impact Health and Safety, e.g., powe 7 lines, integrity of dikes, terrain, etc.) 3081(12/17 2002) 0 ND SAFETY PLAN PART II EVALUATION OF POTENTIAL HAZARDS 1. Chemicals Hazards ❑ Carcinogens: ❑ Corrosives: ❑ Dusts: ❑ Explosives: ❑ Flammables: ❑ Inorganic Gases: ❑ Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / mea restrictions: 2. Personal Protective Equipment VD Level of Protection: ❑ A ❑ B ❑ C 51 Hard Hat. E3:Bafety Glasses/goggles. gSteel toed/shank shoes or boots. ❑ Flame retardant coveralls. ❑ Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR ❑ SCBA A/P cartridge: Safety vest. Two-way communication. PART IV - PLAN APPROVAL �y Plan Prepared b . te: Plan Approved by: "' Date: !/ I