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SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMA-PON L EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: `tel A--GI c �[�l Ui 3. Ehemieals Hazards <br /> Address: 14-A I awe r . ,�,Carcinogens: <br /> Contact Person: Pbone No: ❑Corrosives: <br /> Sweeps Number. ❑Dom: <br /> Proposed Date of investigationlmspection:- -JER Explosives: <br /> (Z1 mumbles: oil filters,solvers <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: r <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑TrmVPipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART M <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Conten: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other operations unless appropriate rationale or restrictions are provided) <br /> //�� CC ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: ")�/ a 4 I ❑Detector Tubes(Specify). <br /> J— ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑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 previous investigation or incidence: <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) Z Hard Hat. <br /> (E Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp) <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> El ❑APR El <br /> etc )_ <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: Jeffrev Wong Dat <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: v1''� Date: <br /> S. 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 />