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SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: { �blC. L <br /> Address: N <br /> I. Chemicals Hazards <br /> /p0. ,,f' <br /> �S—ply-em <br /> cinogens: <br /> Sweeps Number: <br /> Contact Person; .S ' hone No: <br /> 'Corrosives: <br /> Proposed Date of inves[igatioNon <br /> inspecti : IT I Z 0 <br /> C1 Dusts: <br /> ❑Explosives: <br /> JZ.13ammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑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. ❑PCB's: <br /> ❑Igstallation��J�of Borings/Monitoring Wells. <br /> vV <br /> 3. Specific Site l6formation: 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 aro provided) , <br /> y��A (I{ y� ❑Combustible Gas/Oxygen Meter. <br /> 4. Type ofOpermm / •l6 / �yL;(r ,$�Or ❑Detector Tubes(Specify). <br /> 11 Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other,specify' <br /> Documented Groundwater contamination: []YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that apply&describe) Aryllard Ha[. <br /> ❑Hear or Cold Stress: p �4 safety Glasses/goggles. <br /> ° (high ambient temp.) <br /> ❑Noise Sources: Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,(rips,slipping,cavo-ins): <br /> ❑Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> Q Heavy equipment(physical injury&trauma resulting Som moving tE�Safety vest. <br /> equipment): Ti?Two-way communication. <br /> ❑Other,specify TL <br /> 7. Anticipated Biological Hazards; PART IV-PLAN APPROVAL/�/� <br /> Snakes �Iasects piodents ❑Poisonous Plants <br /> l.�Other/Unlmown(specify): Plan Prepared by: 4 /!/• Date: <br /> S. Narrative(provide all information which could impact Health and Safety, Plan Approved by: <br /> rmDate: �Z <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />