Laserfiche WebLink
a <br /> SITE HEAL LH AID SAFETY PIAN, (IS.ASP) FORM <br /> p , <br /> Prepared By f _T V fE p LL Date 'Li IJ6 I g W.O. ©L-1]'S"OV-1 -C>o _ <br /> I. General Information ' <br /> A. Protect Identification <br /> 1. Division _, 2. Department/Office C 5$& ST <br /> II <br /> 4. Site Name S M V �'�" r� 5. Client _ �C <br /> 6. Work Location Address -7-75 9 S. L(Do E I WA- �- x ori . Cf� 952-07 <br /> (Street Address) (City) (State) (Zip) <br /> B. Site History <br /> 1. Describe briefly ti i nr ra 'C_ J,4t <br /> C. Scope of Work <br /> I <br /> 1. Describe briefly 2r i o �n e r ;l z Sa <br /> l l Site visit only. Site HASP not necessary, list personnel here sign-off below: ' <br /> r r Ij r <br /> � l <br /> D. Hazard Assessment and Regulatory Status <br /> I. Indicate Yes (Y)/No (N) to types of hazards anticipated. ( ) Physio-chemical; <br /> Toxic Chemical - Levels (N) >rTLV-TWA, (�) >TLv-STEL,.; (AA >IDLH; (IV) Bio-Hazards; <br /> ( Radiation; (A/) Physical; (ff) Construction type: '�,y Industrial type; <br /> (� Nuclear Industry type } <br /> 2. Site Regulatory Status: C 2g ESARA - (Al) U'.S. EPA, (N) State, (Al ) NPL Site <br /> RCRA - (tJ ) U.S. EPA, (N) State; OSHA - (1V) 1910, (N) 1926, (M State; j <br /> NRC - (r/) 10 CFR 20; Other Fed. Agency - (^/) DOE', (,,L4 USAnW%, (N) Air Force; <br /> Based on the Hazard Assessment and Regulatory Status, determine the Standard HASP(s) <br /> applicable to this project. Indicate below which Standard Hasp will be used and <br /> append the appropriate pages of this Form along with the Stand Plan. <br /> 3. Standard Plan to be used: ( } Stack Test i ( ) 'Air Emissions ( ) Asbestos <br /> ( ) Industrial Hygiene ( ) Life Systems ( ) Hazarcdus Mat. ( ) Construction <br /> { ) NRC/DOE ( ) USAT-UM ( ) Air Force <br /> D. Review and Armroval Documentat'on j <br /> 1. Reviewed By: a. P.M. ! Date <br /> ` b. P.D. v i! Date <br /> c. DSO/RSO I Date i / <br /> d. SHSC i Date <br /> 2. Approved BY: Date <br /> ( ) a. Corporate Health and Safety Dii-ector (CHSD) <br /> ( } b. DSO/RSO(0n1y with specific de1ecmt11gn_by (HSD <br /> Project Start Date a ►t ;End Date This ' HASP Rust be <br /> Reissued/Reapprvved for any activities conducted after:' Date 101 !11 94 <br /> Amendment Date(s) 1. 2. 3. 11 4. 5. <br /> i <br />