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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATIO //l�'.y/ EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1./ ^ '^ n } Gh,mieals Haeards <br /> Address: 11 I 1A a14 1 ®Carcinogens: <br /> Contact Person: 1 T6=r__e,, Phone No: `.S Cl Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:. / ❑Explosives: <br /> p, ��� �Flarnmables: oil filter` solvents <br /> 2. Description and brief narrative of inspection activity. Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. FLMetals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> PART III <br /> 3. Specific Site Information: <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: ❑Combustible Gas/Oxygen Meter. <br /> �r i <br /> E]Detector Tubes(Specify). <br /> 4. Type of Operation: -�a,�VV—�— ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/mea 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 ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ®Heating protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of Hazardous Substance:(fire,explosions, ❑Respirator: ❑APR ❑SCBA <br /> etc..): <br /> cartridge: <br /> ❑Confined space entry:(explosions): ®Safety vest. <br /> C]Heavy (physical injury Y&trauma resultingfrom movieg <br /> ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: d / <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: Jeffrey Wone Date: <br /> ❑OtherfUnlmown(specify): n <br /> Plan Approved by: Date: f� <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />