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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFOFI ATI I� J- - EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: d ( 7i1�1A� L Chemicals Hazards <br /> Address: kp�+T Carcinogens: <br /> Contact Person: T,fd Lt one No. 9 4y" 34 g p Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection: I Z Explosives: <br /> Wlammables: <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 Re)parc . ❑Oxidizers: <br /> ❑Tank/Pipe Removal. '01 t`/- Zr. W a'�' � ❑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 /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> � l � J / ❑Combustible Gas/Oxygen Meter. <br /> / <br /> 4. Type of Operation:�Rn g4-7%1!� ❑erector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO <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) m Hard Hat. <br /> ❑Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <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, ❑Respirator: ❑APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> IAHeavy equipment(physical injury&trauma resulting from moving Wafety vest. <br /> equipment): ERalwo-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> OgpSnakes aInsects ❑Rodents ❑Poisonous Plants Plan Prepared by: Date: / z �- <br /> ❑Other/Unknown(specify): , 1 <br /> Plan Approved by: 1`y F Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, '/J� <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />