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SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> � AA <br /> 1. Site Name: <br /> D 1. Chemicals Hazards k�l <br /> Address: WO S_('lw¢ /Pv, ( n )a Carcinogens:_ <br /> Contact Person:c�rn1— Q0�6r)R— Phone No: `A`�j�, <br /> 1❑�r,Corrosives: <br /> tP <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection:�,�]=1�j—Od ❑Explosives: <br /> ❑Flammables: <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. <br /> PCB's: <br /> ❑Installation ft <br /> Borings//Monitoring Wells. <br /> ❑ <br /> Gic S I <br /> 3. Specific Site ormation: 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 we provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> S. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑fie•specify. <br /> Documented Groundwater contamination: <br /> ❑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 C�D <br /> Physical Concerns:(check all that apply&describe) 'M Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ja Safety Glasses/goggles. <br /> ❑Noise Sources: 15 Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ]Hearing protection. <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> eta.): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space eery:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ZI Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ElOtherlunknown(specify): Plan Prepared by: Date: <br /> (P fY): <br /> y: <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved bDate: <br /> e.g.,power lines,integrity of dikes,ten in,etc.) <br /> EH 23081 (12/17/2002) <br />