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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: �—J" c"� ]. Chemicals Hazards <br /> Address: 1146"Al ` tr} fad 1 <br /> arcinogens:�1�'(Qi� _ rpt <br /> Contact Person: �U.!� Phone No:gM '331-1213 Corrosives: �_. <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigationl nspection: ❑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. ❑PCB's: <br /> ❑In�"'�sgt�a4ativn of Borings/Monitoring Wells. <br /> I9 I NPART III <br /> 3. Specific Site Info tion: <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 /> 4. Type of Operation: �t yC�Itt I� '�. ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO [:1 Other,specify. <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 �i <br /> Level of Protection: ❑A ❑B ❑C Ab <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) $aSafet Hat. <br /> Safety Glasses/goggles. <br /> 0!D-leaJor Cold Stress: °F(high ambient temp.) <br /> aSteei toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: [I APR ElSC$A <br /> A! <br /> El Confined space entry:(explosions): cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Saff ety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: r l <br /> a —4 A _(� <br /> ❑Snakes sects ❑Rodents ❑Poisonous Plants 4 <br /> plan Prepared by: ate: f�" <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: <br /> V <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 />