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SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATIQN � EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: <br /> Address: _J2 Carcinoge1. Chemicals Hazards � - <br /> Contac[Person: ho <br /> Sweeps Number: E-1 corrosives: <br /> Proposed Date of investigation/inspection: El Dusts: <br /> ❑Explosives: <br /> 2. Description and brief narrative of inspection activity: El Flammables: <br /> ❑New UST installation. ElInorganic Gases: <br /> ❑UAR Investigation. PA <br /> El Tank Tank/Pipe Repair. <br /> Tank Closure in Place. Ya Metals:�vyd.Qld_Ipu <br /> . � <br /> ❑Tank/Pi a Removal. ❑Oxidizers: <br /> P ❑Re-excavation. ❑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 /> L <br /> E]Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: �1k, tejP d1— ❑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: ❑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 <br /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> ❑Hear or Cold Stress: of(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,cave-ins): ❑Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(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 Plan Prepared by: Date: 01s7� <br /> E]Other/Unknown(specify): C <br /> R.N 1" <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: C <br /> e.g.,power lines,integrity of dikes,terrain,etc.)_ <br /> EH 23081 (12117/2002) <br />