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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INF RM�TIO�J EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: ss s rK C• tamienIs Hazards <br /> Address: ®Cammogens: <br /> Contact Person: '1� Y_0� ;sAlphone No: () J5Lormsivw: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:_ I ❑Explosives: <br /> gFlammables: 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. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑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 /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> ❑Combustible Gas/Oxygen Meter. <br /> �`.0r(� ❑Detector Tubes(Specify). <br /> 4. Type of Operation: r'W`t <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C OD <br /> 6. Potential Health and Safety <br /> ®Hard Hat. <br /> PP sinal Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> 7Ly.}iear or Cold Stress:_ °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator. ❑APR ❑SCBA <br /> etc..): <br /> A/P cartridge: <br /> ❑Confined space entry:(explosions): <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest. <br /> uipment): ❑Two-way communication. <br /> �1her,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: / <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> Plan Prepared by: Jeffrey Wong Date: <br /> ❑OtherfUnlmown(specify):— c,CN' /n L <br /> Plan Approved by: Date: I <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> g., a es,integrity o dikes,terrain,etc.) <br /> e. p4y' linty <br /> EH 23081 (12/17/2002) <br />