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I <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART TI <br /> GENERAL SITE INFOPATION (I c EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: dd y=tk I al l#0- hl, 1. tamieaIs Hazards ^ <br /> Address: Z I 0 i F. C k GY r W l Caminogens: 'k ` <br /> Contac[Person: Of/aY►A Al KSI';1rt Phone No: 4 ag may-corrosives: �'� r <br /> Sweeps Number: <br /> I ❑Dusts: <br /> Proposed Date of investigation/inspection:_ �' �� ❑Explosives: <br /> 2. Description and brief narrative of �ammables: oil filters.solvents <br /> p inspection activity: <br /> ❑Inorganic Gascs' <br /> ❑New UST installation. ❑UAR Investigation. P.Mt.1, S 0.,r1—Z--'S <br /> ❑Tank Closure in Place. ❑Tank/Pipe RepanC Oxidizers: <br /> Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑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: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> 1I�- �� ❑Combustible Gas/Oxygen Meter. <br /> Tr <br /> 4. Type of Operation: kc ,\ r—"�-I►-R I r, ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other,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 prepous Inv ligation 0 incid7ce: <br /> at ,A1{ ;�It (em a n <br /> SOft 4 t 2wCp ETT20I? <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) ®Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp,) ®Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation: PPtrg�cave-ins):slipping,s,falls,tri ®Hearing protection. <br /> ( P <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space army:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®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 /> Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify); <br /> Plan Approved by: ' vU� Date: <br /> 8. Narrative(provide a6 information which could impact Health and Safety, <br /> e.g.,power lines,integrity of ikes,terrain etc J <br /> A <br /> EH 23081(12/17/2002) <br />