Laserfiche WebLink
1 <br /> IN <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE IN AT 0EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: jn" I <br /> Ghemieals Hazards � O <br /> Address: <br /> ®Carcinogens: <br /> Contact Person: Phone No:...._ ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date ofinvestigation/inspection:_ 2 <br /> ❑Explosives: ✓d �� X <br /> ❑Flammables: oil filters solvents <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑ Re-excavation. <br /> ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other. operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: —CM ` ❑Detector Tubes(Specify). <br /> 1 ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Backgr_ound and description of any prev'ous investigation or incidence: <br /> LCt� G. <br /> 4-4 :t? W 2. Pers <br /> RX1Nonal Protective Equipment <br /> `4 Level of Protection: E]A [IB ❑C ®D <br /> 6. Potential Health and Safety Ab0 el illi ?000 <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑ ❑Flame retardant coveralls. <br /> Oxygen Deficiency: <br /> Excavation: falls,tris sli in cave-ins ®Hearing protection. <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest. — \ <br /> equipment): ❑Two-way communication. �j r/ <br /> El Other,specify ►�l� 3f x'4 1+ <br /> PART IV-PLAN APPROVAL i <br /> 7. Anticipated Biological Hazards: V — <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants 1l <br /> Plan Prepared by: Jeffrey Wonp Date: <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: P'IK' Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain etc.) U + <br /> I44niL A f in n <br /> T— I/ <br /> " U 1 <br /> EH 23081(12/17/2002) <br />