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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: A g C 60J Ka, Chefnieals Hazards <br /> Address: —_ <br /> c� <br /> ®Carcinogens: <br /> Contact Person: Q_Ir S Phone No: ❑Corrosives: <br /> Sweeps Number: <br /> I ❑Dusts: <br /> Proposed Date of investigation/insp tion:_ ❑Explosives: <br /> 2} i9 lammables: oil filters,solvents <br /> 2. Description and brief narrative of inspection activity: / <br /> ❑ Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑ e-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monito g Wells. <br /> 3. Specific Site Information: /f ZPART III <br /> Tank No.: ank Capacity: ( `016 SQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: ank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: GL q ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contaminatio : ❑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 ptevious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C [D D <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> F]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:(falls,trips,slipping, ave-ins): ®Hearing protection. <br /> ❑Handling and Transfer of a Hazar ous Substance:(Fre,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions: A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Z Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑ Insects ❑Roder is ❑Poisonous Plants 6 1 <br /> Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): C <br /> aPlan Approved by: V Date: 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 />