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SITE HEALTH AND SAFETY PLAN <br /> PART I PART A <br /> GENERAL SITE INFO9,NIATIO t EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: Is Hazards <br /> Address: r ®Carcinogens: <br /> Contact Person: 64fhone No: ❑Corrosives: <br /> Sweeps Number: tG7'D,�cts; �G�LI I S <br /> Proposed Date of investigation/inspection:- �❑Ex losives: <br /> dmmables: oil filters.solvents <br /> 2. Description and brief==live of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. gmetals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe 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 Content: Tank Age: I. 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 Meta. <br /> 4. Type of Operation: lr,�J) !�0�N ❑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 instruments <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring inshvments are not used,rationale or activity arm restrictions: <br /> Back and and description of any previous investi tion or incidence: , <br /> K�qA>�JEQ_ 2-;ZC <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 /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cavo-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&tmuma 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 ElInsects ElRodents ❑Poisonous Plants <br /> Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): 'y/ <br /> Plan Approved by: 1 _ Date: <br /> 8. Narrative(provide all information which could impact Hwlth and Safety, / <br /> e.g.,power lines,int 'ty of dikes,tern' petc.) <br /> jos ra tQ !kk <br /> EH 23081(12117/2002) <br />