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SITE HEALTH AND SAFETY PLAN <br /> 1 <br /> PART I PART II <br /> GENERAL SITE INFORMATIONEVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name. �/ Ad vawed '�� —Ghemiaals Hazards <br /> Address: _ _ :'e2_ / 0 ( C' -- — ®Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: I ❑Dusts: <br /> Proposed Date of investigation/inspection:_ ❑Explosives: <br /> ❑Flammables: oil filters,solvents <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 /> ❑Installation of Borings/Monitoring Wells. <br /> PART III <br /> 3. Specific Site Information: <br /> REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: <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: X✓kLk V2,pa i r E]Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: El YES ❑NO <br /> Back and and de cripdon of an revio estigatio r incident : <br /> 2• Personal Protective Equipment <br /> Level of Protection: ❑A ❑B Cl C ZD <br /> b. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boors. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions. <br /> ❑Respirator. ❑APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving (0 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 Plan Prepared by: Jeffrey Wong ` <br /> ❑Other(Unknown(specify): <br /> Plan Approved by: R U Date: <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(12117/2002) <br />